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CONTAINING The Diseases of the Alimentary Canal, Diseases of the Respiratory Organs, " Circulatory Apparatus, " Glandiform Ganglions, " Glandular Organs, M Nervous System, " Organs of the Senses, " Organs of Reproduction, Diseases involving Various Organs, &c. &c. IN TWO VOLUMES OCTAVO. THIRD EDITION BROUGHT UP TO 1841, OF NEW REMEDIES. THE METHOD OF PREPARING AND ADMINISTERING THEM; THEIR EFFECTS CFON THE HEALTHY AND DISEASED ECONOMY, &c. inflam™l°T due**," isfcl.ac J^ causes give a tendency to d.seases which require evacuations, but certainlv not to true in. flammations (except.ng in the case of the specific inflammation of gouM A^in when inflammation, are excited in such habits, they show violent symptomf and demand active reme.es; but this ,8 a very different thing from their being pLuiaSy'apt toc?ur in ?0'ch inflammation, (Anatomical Characters of.) 83 part of a body, in other parts of which it has been previously subsisting for some time, there will be predisposition to effusion of a peculiar character, and much loaded with fibrin, or even with pus, as might be expected from what has been said of the gradual alteration of the whole blood in consequence of inflammation; and this appears to be exemplified in many cases where rheumatic inflammation attacks the heart, and in a few where it attacks-the lungs, and produces within a very short time, great effusion of solid matter. Anatomical Characters of Inflammation.—We proceed now to offer a very general sketch of the different forms which inflammation assumes and the effects which it produces, as it affects the different textures of the body; first, supposing the constitution on which it acts to be previously sound and healthy, and the in- flammation to show what has been very reasonably called its simple or healthy character. In cellular substance, healthy inflammation tends to the effusion of lymph, by which the cells are loaded, swelled and condensed; while but little, even of se- rous effusion, extends beyond the part where the pain is felt. If the inflammation is intense and not arrested by remedies, the central part of the effusion soon be- comes purulent, but is still bounded by a cyst, consisting of cellular substance con- densed by effused lymph, and is thus prevented from diffusing itself. This cyst becomes gradually thinner, especially in the directions in which least resistance is offered to its gradual distention, by the increasing effusion of pus within it, and at the same' time the neighbouring sound parts in the same direction are gradu ally wasted by the " progressive absorption" determined by the pressure, and thus the abscess makes its way to the surface of the body. This process is li- able to great variation in different cases; sometimes the inflammation, although long-continued, never goes beyond the effusion of coagulable lymph; sometimes, although of slight intensity, it forms purulent matter early; sometimes the puru- lent effusion is never circumscribed by lymph; and sometimes there is a rapid sloughing, as well as purulent effusion; but all these may be regarded as the effects of peculiar or specific forms of inflammation, and will come under view afterwards. Partial sloughing, however, i. e. death of a portion of the cellular membrane, in consequence of inflammation, is an effect to be apprehended mere- ly from intensity of the disease. This form of inflammation is clearly of the same type as that which takes place in the parenchymatous viscera, to be men- tioned immediately. The healing of wounds, whether by the first intention, or by granulations fill- ing up the breach of texture, is generally held to be in all cases the result of in- flammation, and of the organization of the lymph thrown out by inflammation, although sometimes on so minute a scale as hardly to be distinctly recognised: the latter process is attended with effusion of pus on an exposed surface, and both are attended by an active absorption of the thinner part of the effusion on the inflamed surfaces; the new matter which is formed is always, in the first in- stance a dense or compact cellular substance, but afterwards, probably, in all parts in which the process can go on at all, assumes the form and vital properties of the texture in which it is formed. On membranous parts there is some difference in the usual effects of healthy inflammation, but always an obvious approximation to the type exemplified in the cellular membrane. On the skin it leads very certainly to the effusion of serum externally, and elevation of the cuticle, but at the same time to effusion of lymph into, and condensation of, the true skin itself, and frequently affects in the same manner more or less of the cellular substance beneath. It is a mistake to suppose that inflammation has necessarily any peculiar tendency to spread ex- tensively along the skin; for healthy inflammation, such as is excited by burns, blisters, or bruises, has no such tendency. When inflammation of the skin is of some duration, particularly if it is aggra- vated or increased by repeated irritation, it generally goes on to effusion of pus, 84 inflammation, (Anatomical Characters of.) and often subsequently to ulceration: and in certain circumstances, to be after- wards stated, it frequently terminates in gangrene. The inflammation of the serous membranes within the body, is that which shows the greatest tendency to extend itself along the surface, being rarely seen on any of those membranes, in the head, chest, or abdomen, confined to a very limited extent of surface. On these membranes it tends always to effusion of serum, which soon becomes either loaded with lymph, so as to take the form of a thin jelly if drawn from the living body, or more generally, is found to be mixed with flakes of soft whitish or yellowish lymph, while a similar exudation of lymph incrusts the membrane itself, and gradually undergoes various important changes. This false membrane often becomes organized by the blood it receives from the arteries of the inflamed surface; and it afterwards becomes of less bulk and of firmer consistence, in consequence of the absorption of part of its substance, both into the vessels of the surface from which it came and into the vessels (chief- ly veins) which are formed within itself. This tendency to absorption in the effusions from healthy inflammation, always to be expected after the inflamma- tion has subsided, is the essential point of distinction between these effusions and other growths or tumors, composed of materials foreign to the healthy body, and constituting the strictly organic diseases—tubercles, scirrhus, melanosis, en- cephaloid disease, &c; and it is of the utmost importance to the practitioner to understand distinctly the circumstances in which this healing process of ab- sorption is to be expected, and the duration and extent of its operation, because it is the grand resource to which he must look in the later stages of "those cases in which inflammation is not adequately opposed during the first part of its progress. This observation applies particularly to the inflammatory effusions which may very frequently be detected in the cavity of the thorax. In many cases, where the inflammation of these membranes is of some con- tinuance, the effused fluid assumes gradually the form of pus, as is most remarkably seen in cases of empyema, often called chronic pleurisy, but oftener the effect or sequela of acute pleurisy; but if the inflammation has been of healthy character, the purulent effusion here, as in the cellular substance, is always preceded and bounded by coagulable lymph. In this manner, circumscribed collections of pus are often formed among the folds of the intestines from peritonitis. On the serous membranes themselves, mflammation of the more chronic or less intense character has frequently a very peculiar ulterior effect—that of making them rough and uneven and thickening them by interstitial deposition of lymph, and at the same time shortening or puckering them up. This is remarkably seen in many cases where such inflammation has affected the peritoneal surface of the liver and of the intestines, of the Fallopian tubes, &c.: it is thus that the omentum becomes shortened and thickened by inflammation; and it is the same change, consequent on inflammation, which so injuriously affects the structure of the inner membrane of the blood-vessels and of the different valves of the heart Ulceration, as a consequence of healthy inflammation, probably takes place on the serous or synovial membranes only after long-continued effusion, and partly in consequence of the pressure of the effused fluid; but it is often observed in these circumstances, and leads to the ultimate discharge of that fluid in various ways to be afterwards noticed. On the pericardium the same results follow from inflammation as on the serous membranes; but it is important to observe, that the very common rheumatic in- flammation, even if rapidly fatal, is found to be there attended with a peculiarly copious exudation of fibrin, with a smaller proportion of serum than is found in those cases where no previous rheumatism has affected the patient. On mucous membranes there is more variety in the effects of inflammation. On all of these, when inflamed, there is a brief diminution, very soon followed by a permanent increase of the secretion: this secretion is changed from its natural condition, and undergoes farther changes as the inflammation advances, being first more watery, but afterwards thicker than usual, and in the case of the lining inflammation, (Anatomical Characters of.) 85 membrane of the urinary passages, and in some cases where the tunica conjunctiva of the eye is affected, soon becoming decidedly purulent. A similar change is seen to be frequently, although more slowly, produced on the mucous mem- brane of the bronchiae; rarely on other mucous membranes, where there is no ulceration. On some of these membranes lymph is thrown out rapidly, so as to form a continuous false membrane in the larynx and trachea in the croup of children; occasionally so as to form a similar false membrane in the intestines, but more generally so as to form numerous small irregular patches in the great intestines in dysentery: in some instances the chief mischief is done by inflam- matory effusions in the sub-mucous tissue; as in the oedema glottidis, and again in the usual mode of formation of strictures of the urethra. On the mucous mem- brane of the alimentary canal, inflammation has not the same tendency to spread extensively as in the air passages; and the effect chiefly to be apprehended in the former part, is the formation of numerous circumscribed ulcers, each preceded and bounded by more or less deposition of lymph, sometimes attended with sloughing. In the air passages, and in the bladder and urethra, this tendency to ulceration from simple inflammation is much less perceived; but the peculiar tendency of inflam- mation there, as to a certain degree in all mucous membranes, is to degenerate from the acute into the chronic form. Sloughing or gangrene may be said to be a rare termination of simple healthy inflammation in any internal part, except the alimentary canal, from the stomach downwards. In these parts it is a common result of such inflammation, both in the serous and in the mucous membranes; and for this peculiarity of inflammation of these parts we have probably a sufficient reason in the enfeebled state of the heart's action, afterwards to be noticed, as usually attending it. In the parenchymatous viscera, the natural course of inflammation is to the deposition of lymph, and then to the formation of circumscribed abscesses, as in the cellular membrane. This is most remarkably seen in the liver, but also in the pancreas, spleen, kidneys, lymphatic glands all over the body—occasionally in the brain and in the lungs. < The usual course of inflammation in the lungs is not, indeed, to the formation of circumscribed abscesses; but the inflammatory effusion in them undergoes the same changes as in cellular membrane: first, serum is thrown out loaded with fibrin; gradually the latter ingredient predominates, and the solid, but soft grayish granular matter, characteristic of hepatization, chokes up the cells of the affected part of the lungs, and gives it the granitic appearance accurately described by Laennec. But if these changes are not fatal, this -effused lymph is often gradually converted into pus, constituting the third stage of pneumonia: and if this is only a partial change, the purulent matter may be expectorated, and the spongy structure of the lung probably restored. Whether the lymph that has been effused into hepatized lung is afterwards liable to absorption, is a more difficult question: it is certain that, in some instances, a portion of lung thus condensed remains nearly stationary for life, acquiring only a gradually darker colour, from the usual black matter of the lungs. The ultimate termination of inflammation of the lungs in sloughing or gangrene is not uncommon, but is very generally the result either of inflammation of a pecu- liar or specific character, or of a complication of inflammatory action with other disease, enfeebling the circulation. It may readily be understood that, in some of the parts already mentioned, one effect of the inflammatory effusions will be to soften the texture. This is done to a certain degree- in the early stage, when inflammation is active, by effusion of serum, as in the lungs and liver, but more remarkably in some parts in a more advanced stage, when softening seems to be a prelude to ulcerative absorption. This is seen in the lining membrane of the arteries, and still more in the mucous membrane of the bowels. In the brain, softening with some variety of colour (the ramollissement rouge or jaune) seems the most common effect of fatal inflamma- tion : it often terminates in a peculiar form of gangrene, but if so partial as to 86 inflammation, (Anatomical Characters of.) admit of recovery, is found to leave the part affected in a state nearly resembling caries of the bones. It must, however, be remembered, that in all these parts there may be softening, especially of that kind which is nearly unattended with change of colour, which we have no reason, either from its accompaniments or effects, to ascribe to any process resembling inflammation, and regard as a mere " perversion of nutrition." On the other hand, from another form even of healthy inflammation there fol- lows a permanent hardening of the affected part. This, as may readily be sup- posed, is commonly the result of a more chronic inflammation in which there is time for the gradual absorption of the serous part of the blood originally effused. We see it exemplified in many chronic cases of inflammation, even of erysipe- latous inflammation in the cellular membrane of the extremities: we see it in the serous membranes, and where the effused lymph sometimes becomes gradually bony, especially as Laennec states, when the effusion has been originally mixed with blood; in the synovial and fibrous membranes: we see it in* the lungs, liver, spleen, kidneys, testes, mamma?, and brain. In all these parts this induration from inflammation sometimes approaches closely to, or graduates into, strictly organic disease, tubercles, or scirrhus; but we meet with many cases in which it may be accurately distinguished from any of these; and in some such cases its essential distinction is shown by its being distinctly liable to absorption. The symptoms resulting, however, from this effect of inflammation changing the texture of these viscera, are hardly to be distinguished from those of strictly or- ganic diseases equally affecting their functions. In the case of the substance of the brain being much altered, whether by the effect of inflammation or by organic disease, there is very generally, sooner or later, serous effusion into the ventri- cles; and it is often hardly possible to judge how far the symptoms are caused by this complication. The texture, both of arteries and veins, is also remarka- bly liable to induration from inflammation. This is seen in the acute inflamma- tion of the veins, affecting this substance generally; and in the more chronic form of inflammation, which so often affects the lining membrane of arteries, the first change is very generally the deposition of patches of lymph, hardening the tex- ture, and afterwards degenerating into various forms of organic lesion—irregular, atheromatous, and bony deposites, and ulceration. Mucous membranes are perhaps the only texture in the body which never becomes hardened by simple inflammation. In regard to all the textures now mentioned it is to be observed, that when the inflammation excited in any one is very intense, it is to be expected to spread into the neighbouring textures, as we see in urgent cases of pneumonia, attended with pleurisy or bronchitis, or both—in violent inflammation of the brain and its membranes, of the liver and peritoneum, even of the peritoneum and mucous membrane of the bowels. But when the inflammation is of less intensity, it will often exist long, spread far, and produce its full effect on a membrane" without touching the contiguous textures, as we see in bronchitis, pleurisy, dysentery, &c, even originally acute, but not very violent—taking gradually the chronic form, and where the whole disaase is strictly confined to the texture first affected. Inflammation affecting the fibrous membranes which invest the bones and con- tribute to their nourishment, as well as that which affects the bones themselves, tends to effusion of lymph, which is gradually converted into bonv matter, as we see not only in cases of fracture but in cases of nodes, of necrosis, &zc. In the bones, as well as between the bones and periosteum, collections of purulent mat- ter occasionally form ; but the ulterior results of inflammation most usually seen in bones are caries and exfoliation, or necrosis, corresponding to the ulceration and sloughing, or gangrene, of soft parts. And similar results are often seen in cartilages in consequence of inflammation, the first effect of which, in that tex- ture, is to cause deposition of earth)- matter, and assimilate it to bone before it undergoes these farther changes. It must, however, be observed, that these ul- terior consequences of inflammation of bones are much more frequently observed inflammation, (Symptoms of.) 87 in cases which have a peculiar or specific character, than in simple or healthy inflammation. Muscular fibres have this peculiarity in regard to inflammation, that it may be doubted whether their nutrient vessels ever yield distinct effusions, either of lymph or pus, although they may be involved in, and even softened and absorbed by, the effusions from neighbouring textures. But two remarkable effects are observed from inflammation on muscular texture, 1. That when certain membranes lying in contact with muscles are inflamed for some length of time, the muscular fibres are excited to increased action, and thereby ultimately to hy- pertrophy. This we see remarkably in many instances in the heart, when either of its lining membranes has been inflamed: we see it also in the bronchia?, as a consequence of inflammation of their mucous membrane; in the bladder of urine, when its mucous membrane is inflamed; and sometimes in the intestines, when the peritoneum investing them has been the seat of chronic inflammation. But it seems equally certain that in other cases, where inflammation has more directly affected the muscular fibres themselves they lose their contractile power, and appear to be lengthened, but attenuated and relaxed. This appears to be re- markably the case in some instances of inflammation affecting the muscular fibres of the heart, likewise in acute inflammation of the intestines, and in rheumatic inflammation of the voluntary muscles, probably in those cases especially where the muscular fibres have been themselves affected, and their organization injured: but we must admit that we do not distinctly understand in what manner this pe- culiar result should follow inflammation. Some of the ulterior consequences of the different processes dependent on in- flammation which we have considered, may be briefly noticed as part of the history of inflammatory complaints. When extensive suppuration has taken place in the liver, the pus effused causing by its pressure adhesive inflammation, and then ulceration, may make its way, sometimes to the surface of the body— sometimes into the stomach or colon—sometimes into the cavity of the abdomen or chest—sometimes into the cells of the lungs and bronchia?: so also pus from the sac of the pleura makes its way not unfrequently either through the pleura costalis to the surface, or through the pleura pulmonalis into the lungs and bron- chia?., causing one form of empyema and pneumo-thorax. And suppurations commencing in the cellular substance of the back make their way frequently along the course of the psoas muscle to the groin, occasionally through the pleura costalis and pulmonalis into the cells of the lungs. Again, when ulceration takes place in the lungs; the pleura pulmonalis is occa- sionally eroded, and matter and air make their escape into the cavity of the chest, and immediately excite inflammation there, producing another form of em- pyema and pneumo-thorax. Or when the mucous membrane of the stomach, in- testines, or gall-bladder, has been ulcerated, perforation of all the coats sometimes ensues, and the matter effused coming in contact with the serous membrane, uni- formly excites violent inflammation. General view of the symptoms of Inflammation.—The symptoms which re- sult from inflammation of the healthy or simple characters hitherto considered, may be arranged in a general view according as they are local, distant, or general over the body. We need not enlarge on the local symptoms of inflammation of external parts —whether of the true skin, where the redness as well as the pain, heat, and swelling, are obvious, and where the effusions or other results of inflammation take place under the eye of the observer;—or of the cellular or other textures immediately beneath the skin, where the redness only is concealed from the eye, and where the effusions of serum and of lymph, and the gradual formation of pus, may in general be easily detected by the touch;—or of the bones, the muscles or fascia?, the joints of bursa?, where the peculiar form of the swelling, attended by heat and pain, and the kind of pressure, or of attempted motion, by which the 88 inflammation, (Symptoms of.) pain is most distinctly excited, in general sufficiently indicate both the existence of inflammation and the texture chiefly affected. It is in the interior of the great cavities of the body that we have the greatest difficulty in detecting the seat, and sometimes even in recognising the existence of inflammation; yet, by care- ful observation, in a great majority of cases not only the existence of inflamma- tion and the organ affected, but even the texture in which the inflammation is chiefly seated, may be distinctly made out. , c ■ ■ c ■ The symptoms on which our attention is fixed by the definition ot internal inflammation o-iven by Cullen, the concurrence of fever with fixed pain m some internal part, °and deranged function of some internal organ, demand the most careful study. They are of themselves sufficient to guide the practice, and very frequently do guide it almost exclusively, in the early and most remedial part of those diseases, which are more under the control of remedies than any others that come under the care of the medical practitioner: but as each disease ad- vances, more precise information as to its seat may very generally be obtained, and is not only satisfactory to the practitioner, but often important as regulating the details of practice. In such investigations the pain, although often the most urgent symptom, and sometimes very characteristic, is in general with a view to diagnosis, the least important part of the combination of symptoms. It is usually acute in the in- flammation of the serous membranes, but comparatively slight, or only occasion- ally felt when the mucous membranes (particularly in the thorax,) or when th( substance of the viscera, the brain, lungs, heart or great vessels, liver, or kidney: are inflamed. And the pains felt either from slight inflammation of the parieter of the chest or abdomen, or from internal diseases not inflammatory, are not onlj equally or more intense than those of active inflammation, but in some constitu tions are attended with very considerable febrile symptoms, as we see continuall) in the headaches and in the neuralgic pains internal and external, of irritable sub jects. The local symptoms which give us the most precise information are not onl) those which indicate derangement of the functions, of parts, but partly also thosi which indicate alteration of the sensible qualities, or perceptible actions, of inter nal parts, as modified by inflammation and by effusions^ and it is in detecting al terations of this last kind that the greatest improvements have lately been effected, particularly by the French pathologists. These have been called by some the physical signs of disease, but this restricted use of the term physical is obviously liable to objection, and has not become general. Thus inflammation of the heart, or large arteries, not only produces palpitation—strong and sometimes irregulai pulsation—but alters the sounds heard in the situation of the heart, either on per- cussion or auscultation, or both; and in this way we can often clearly distinguish inflammation and effusion on the pericardium from that on the inner membrane lining the heart, arteries, and valves. Again, inflammations of all the different textures contained in the lungs cause hurried breathing and dyspnoea; but if the pleura is inflamed, we observe the impeded movement of that side of the chest, and soon after the dulness on percussion, the suppressed respiratory murmur, perhaps even the distended intercostal spaces and displaced heart; if the sub- stance of the lungs, we may detect various modifications of the sound of respira- tion—sometimes the crepitous rale, oftener the bronchial or suppressed respira- tion, and bronchophony; and likewise we have often the truly characteristic peripneumonic sputa; if the bronchia?, we have the obvious wheezing sound, and the characteristic bronchial rales, the extent of which will often reveal a suf- ficient cause for urgent dyspnoea. Again, inflammation of the mucous membrane of the bowels is not only at- tended with occasional pain and with a loose state of the bowels, but also (at least if the great intestine i3 affected) widi the excretion of altered mucus, often mixed with blood, distinctly characterizing its nature. A similar observation applies to the inflammation of the bronchia?. And it has only lately been ascer- inflammation, (Symptoms.) 89 tained that a particular form of inflammation of the kidneys, even when unat- tended with pain, shows itself unequivocally by rapidly increasing albuminous impregnation of the urine, which is of low specific gravity. It may easily be understood that inflammation of the brain will cause less alteration of the sen- sible qualities of any part of the body than that of almost any other organ, but the alterations in the condition of the eyes, and of the iris especially, which often attend it, are nearly of this character. Although Cullen's diagonastic mark, " the la?sa partis interna? functio," is very generally applicable to internal inflammation (as we see in impatience of light from inflamed eyes, deficiency of smell from inflamed nostrils, various forms of delirium, or stupor, or spasm, from inflamed brain, in the "vox rauca" and " tussis clangosa" from inflamed larynx, dyspnoea from inflamed lungs, vomiting of ingesta from inflamed stomach, costiveness or diarrhoea from inflamed bowels, according to the membrane chiefly affected, dysuria from inflamed bladder, &c.,) yet it is very important to remember, that, in the case of those organs, the whole of which are not necessarily concerned in the performance of their as- signed functions, inflammation may affect a part, while the function may be still so well performed by the rest, as to prevent any outward indication of dis- order. It is thus that we may have partial inflammation of the lungs without obvious dyspnoea, especially when the whole quantity of blood requiring to be arterialized in the lungs is less than natural, and therefore latent inflammation of the lungs in feeble habits. So also the liver may be partially inflamed, while a sufficiency of healthy bile is thrown off by the sound portions; indeed, it must be admitted, that both in acute and chronic cases, any indications that we have of altered function of the liver are exceedingly uncertain. And thus, also, in- flammations of portions of the brain may take place, while all the functions de- pendent on that organ appear to be well performed by the remaining sound parts —a fact which has certainly not been allowed its due weight in some speculations on the uses of individual portions of the brain. Next, there may be symptoms in parts distinct from, although adjoining to, those actually inflamed, clearly indicating the seat of internal inflammations. This is sufficiently illustrated by the effect of inflamed tonsils, or inflamed larynx, in making deglutition difficult; or the very characteristic effect of inflamed peritoneum, in checking the descent of the diaphragm, and making the respira- tion thoracic. But the most numerous of the symptoms showing themselves in distant parts in consequence of internal inflammation, and often giving much assistance in characterizing these inflammations, are those usually called sympathetic phe- nomena, and of these there are two distinct classes, the sympathetic sensations and sympathetic actions. The first of these are the cases where, in consequence of inflammation in some internal part, pain is felt, distinctly referred to some external part—generally referable to known nervous communications of the two, and illustrated by the pains felt at the extremities of a nerve on irritation of its trunk. Of this kind are the pain of the right shoulder attending inflammation of the liver or dia- phragm, pain at the knee attending inflammation of the hip joint, pain stretching round the thorax or abdomen attending inflammation of the spinal cord, pain down the spine or in various limbs attending inflammation of the brain. Again, when we see vomiting attendant on inflammation of the brain, stomach, liver, bowels, uterus, or bladder, the action of the diaphragm and abdominal muscles is called sympathetic, and is often a guide in the diagnosis of the disease. It depends on what has been lately and reasonably termed a reflex action of the medulla oblongata and spinal, cord, with which the sensation of nausea is con- nected, certainly as a general accompaniment, probably as a link in the chain of causation. And it is in the same manner that inflammation of the mucous mem- brane of the air-passages causes cough, that of the mucous membrane of the Vol. I.—12 90 inflammation, (Symptoms.) colon, or rectum, causes tenesmus, and that of the mucous membrane of the blad- der causes strangury; the actions of various and even distant muscles, in all these cases, being only an excessive degree of those sympathetic actions which are naturally linked with the healthy irritation, and with the excited sensations, of those mucous membranes, for the useful purpose of the expulsion from the body of the excretions that pass off from those mucous surfaces. As to the general fever which co-exists with these local symptoms in cases of internal inflammation, it is important to observe, 1. That although in the case of simple and healthy inflammation we are ac- customed to regard the constitutional fever as the effect of the local inflamma- tion, still cases are not wanting where the febrile attack originating, e. g. from cold, distinctly precedes any local symptoms, and has been thought to contribute to their production. This is most observable in some cases of cynanche ton- sillaris and inflamed mamma, when the organ that becomes inflamed is so situ- ated, that if its inflammation had readily preceded the febrile attacks, it seems difficult to understand how it could have escaped notice. 2. That in the more common case, where the symptoms of the local inflam- mation exist in a slight degree for some time before the general fever declares itself, the first constitutional symptoms sometimes takes place very gradually and insidiously; but in many cases there is a sudden and well-marked attack of rigors, which it is always very important to mark, because the sooner thereafter that the vigorous antiphlogistic measures are employed, the more confidence we may have in their efficacy. 3. That in early life, and in persons of sanguine temperament or excitable habit, the degree of febrile re-action which will attend any given extent of inflam- mation is much greater than in advanced life, or in persons of feeble habit or more phlegmatic temperament; and that, in the former case, the febrile symptoms may often be observed to continue for a few days, after the most urgent at least of the local symptoms have ceased, and when no farther active treatment is re- quired to cause its decline. On the other hand, a rapid and decided abatement of all the symptoms of the constitutional fever attending inflammation is always of great importance, and warrants a favourable prognosis, even although it be ob- served that the inflammation spreads, and the inflammatory effusions increase, for a time, after that change. This may be particularly remarked in some cases of pleurisy and pneumonia, and corresponds to what we see in cases of external inflammation. 4. That even in the same persons, the degree of febrile re-action consequent on inflammation seems to vary remarkably according to the seat of the inflammation, and is therefore by no means in uniform proportion to its extent. Inflammation ot the tonsils is attended, in many persons, with a higher degree of fever, in pro- portion to its extent, than probably that of any other organ; and the inflamma- tion of the serous synovial membranes is usually attended with more fever than that of equal importance in the mucous membranes, or parenchymatous viscera. 5. That although the state of the circulation which attends simple or healthy inflammation m its early stage is that which is strictly called inflammatory fever, and which is chiefly characterized by firm and full pulse, and enduring'heat of skin, not easily reduced by evacuations, yet there are some instances of remarka- ble modification of this febrile state. The fever which attends inflammation of the stomach and intestines is characterized in most cases by an early and often rapid depression of the heart s action, strongly resembling, and evidently illustrated by, the strongly sedative, sometimes quickly fatal, effect produced on the heart's ac- tion by violent injuries of the abdomen. An effect somewhat similar results, in many cases, from inflammation of the kidneys, uterus, bladder, and larger joints; and in all these cases, the peculiar sensation (a combination of nausea with pain) attending the inflammation, may be reasonably regarded as the medium of trans- mission ot this peculiar sedative influence to the heart. inflammation, (Symptoms.) 91 Again, if the system has been strongly affected by some other influence, either previously to, or stimultaneously with, the excitement of in flammation, the fever attending that inflammation is often remarkably modified, and may take very much the typhoid form. This is especially observed in the case of inflammation attacking a constitution in which the nervous system has been habitually influ- enced by peculiar stimuli, such as alcohol taken in excess; also in the case of inflammation from an injury which gives a violent shock or concussion, and per- manently enfeebles the heart's action; and in the case of inflammation attended with the introduction of peculiar animal poisons into the system, which will be afterwards more particularly noticed. 6. That where the different effects of inflammation already stated have taken place to any considerable extent in any organ, it must be expected that the symptoms of the general fever attending them will undergo a change; and this change of the general symptoms is always veiy important to be marked, as it generally demands a material alteration of the remedies employed. The nature of the change is different according to the organ affected; in some cases, as in acute abdominal inflammation, and also, although at a later period, in acute pneumonia or bronchitis, it is mere depression of the strength of the heart's action; in the case of inflammation in the brain, or at the heart, there is a more peculiar alteration of the heart's action. But the most striking and most gene- ral is the transition of the inflammatory fever to the form of hectic, which most generally attends the processes of suppuration and ulceration. This often begins by rigors, and is marked by evening exacerpations (sometimes two in the day,) and by morning sweats with abatement, but not perfect solution, of the fever,— by a slight degree only of the thirst, anorexia, or disorder of the organic functions, usual in fever,—by the absence, until the very last stage, of delirium, or other derangements of the nervous system—by the long continuance of the febrile state and progressive emaciation and debility—and, towards the end of most fatal cases, by diarrhoea, and a florid, often aphthous, state of the mouth and throat, often connected with ulceration of the mucous membrane of the bowels, chiefly of the ilium. These affections of the mucous membrane seem very similar to those which are so apt to attend insensibility of this surface from palsy or lesion of nerves. This state of hectic fever is much more distinctly marked in young and irritable constitutions than in others, and in such constitutions is the result of various other long continued diseased actions besides suppuration. It has been often stated, that a sudden sinking of the pulse, coldness of the skin, and collapse of the features, succeeding to inflammatory disease, are an effect and an indication of gangrene. But in some cases of inflammation, par- ticularly in external parts, gangrene takes place where there is no such sinking of the circulation; and in many cases of inflammation in all parts, e. g. in the lungs or bronchia?, but more particularly of abdominal inflammation, this sinking takes place and is fatal, without gangrene showing itself. Such a state of the circulation following inflammation, therefore, is to be considered as a fre- quent attendant, and often as part of the cause, of gangrene; but not as its effect, nor necessarily as its indication. In some cases of inflammation the change which takes place in the febrile symptoms in the advanced stage of the disease, when the inflammatory effusions have in general made some progress, is different, e. g. in inflammation within the brain, the slow or irregular, and afterwards the very frequent, pulse is to be expected: in cases of inflammation of veins, the fever usually takes gradually the form of typhus. But in every case where we have any manifest alteration of the general febrile symptoms, combined with persistence of the local symp- toms, whether these last indicate deranged functions, or altered sensible qualities of parts, we must regard the period as one of great importance both as to the prognosis and the practice; indicating generally a stale of matters in which the active antiphlogistic treatment is no longer advisable. 92 inflammation, (Varieties and Complications.) Varieties and complications of Inflammation.—This brief summary of the mor- bid anatomy, and of the symptoms, of inflammation, would be very imperfect if it did not include some statement of the varieties to which the process is liable. These may be arranged in two great divisions, in the first of which the variations are in the intensity or duration only of the disease; in the other they are in the nature of the organic changes to which it leads; and the differences from the more usual type are in the one case only in degree, in the other in kind. I. Of the first description is the important distinction, which has very pro- perly attracted much attention of late years, between the distinct and the latent form of inflammation; the latter term being applied to cases, not uncommon, where internal inflammation takes place, and produces its usual effects on the textures concerned, with so little of its usual symptoms, as not to be recognised, without very unusual care and discernment during life. The absence, or slight degree of the symptoms of inflammatory fever is very generally to be ascribed, in such cases, to a want of what is usually called mo- bility or excitability in the constitution. This languid state of the constitution (probably both of the nervous and vascular system,) is remarkably observed in the black varieties of the human race as compared with the white; in the expe- rience of physicians in this climate, it is much oftener dependent on age than on any other cause; to a certain dagree it may often be remarked in persons of the lower ranks as compared with those of the higher, who have been accustomed to a more luxurious mode of life. The absence of the usual local symptoms in cases of latent inflammation may be ascribed to two distinct causes—sometimes it depends on a state of great debility and emaciation, in which the whole quantity of blood sent to any organ is considerably less than usual, and therefore less suffering, and less obvious de- rangement of function than usual, results from its obstructed and disordered motion there; thus it is, that latent inflammations, particularly in the lungs, frequently occur in convalescents from acute diseases. At other times, some of the usual local symptoms are obscured merely by the concurrence of other diseases im- pairing the sensibility, as in many cases of typhoid acute diseases, and again in many cases of palsy, or other chronic affections of the brain. As it is obvious that what have lately been called the physical signs of disease, i. e. symptoms drawn from observation of altered sensible qualities of parts of the body (e. g. those furnished by percussion and auscultation,) can not be ob- scured in these ways, a peculiar value is attached to them in suspicious cases of this kind: but it must also be observed, that as many indications of this kind may be given by chronic as well as by acute diseases, much caution is required, in drawing inferences from them as to the existence of inflammation, unless they are supported by some at least of the other symptoms usually combined with them in inflammatory cases. The other distinction to be noticed under this head, is into the acute, sub-acute, and chronic forms of inflammation. The term sub-acute is a proper one, because there are cases of inflammation, sometimes occurring idiopathicallv, oftener per- haps symptomatically, either in combination with febrile or e xanthomatous dis. ease, or with chronic diseases, functional or organic, which present die -symptoms of inflammation, and produce more or less of the effects of inflammation within a short time, but which never attain any great extent or intensity, nor effect oreat alterations of structure, and can be controlled without any very active treatment. The mucous and serous membranes present many examples of this kind easily ascertained both by the symptoms during life and bv the appearances after death. I he term chronic is properly applied to those cases in which the same effects, the same or similar effusions and organic lesions, are produced as in the most in- tense inflammations, but much more slowly, and with much less urgent symp- toms, particularly less constitutional fever. Manv cases of this kind are the sequela? of acute or sub-acute inflammation, e. g.'chronic catarrh, chronic diar- rhoea or dysentery, and gleet; but there are other cases in which, although the inflammation, (Varieties and Complications.) 93 lesions effected are decidedly those of inflammation (as distinguished from the formation of adventitious textures,) yet the attack is gradual, the progress slow, the pain or other uneasy sensations when the patient is at rest, slight, and the febrile symptoms hardly perceived, until such lesions are completed as greatly embarrass the functions of the parts, and cause much weakness and emaciation of the whole body. Of this kind are some cases of chronic pleurisy, in which enormous accumulations of pus are gradually formed; some cases of cold or chronic abscess in which perfect pus is formed in the cellular membrane in various parts, with no other symptoms than such as attend the formation of chronic tumours; many cases of endocarditis, or inflammatory deposites on the internal lining membrane of the heart and arteries—some cases of chronic peri- carditis, and of chronic peritonitis; and likewise many cases of disease of the lungs, liver, kidneys, &c, where nothing but coagulable lymph is deposited in those organs, but where the whole progress of the disease is not only insidious, but very much slower than that of acute inflammation, and the characteristic mark of which, on dissection, is induration of the texture affected, contrasting remarkably with the softening, which, as formerly noticed, is usually observed in the more acute inflammations of the same textures. II. Of cases which are properly referred to the general class of inflammations, because they are cases of pain, swelling, heat, and redness, more or less intense, followed by peculiar exudations from the vessels of the affected parts, but in which the products formed, and the whole progress and terminations usually observed, are specifically different from those of simple inflammation of the same parts, it were easy to make a long enumeration, particularly of those seen on the surface of the body, but the peculiar inflammations which are of the highest importance are the following:— 1. The Scrofulous inflammation in all parts of the body is produced by the same exciting causes as the healthy, but is usually of a sub-acute or chronic cha- racter, attacking more slowly and producing less pain, less heat or swelling, and a more livid or purple colour, in the parts affected, and less firmness of pulse and heat of skin in the febrile re-action, and less influenced by antiphlogistic treatment, whether general or local. In these respects it is hardly to be distin- guished from simple chronic inflammation; but even in its earlier stages it is often farther and properly distinguished in two ways, 1. By the description of persons whom it affects; and, 2. By the parts in which it is most frequently seated. It occurs chiefly in young persons (from the age of two or three to thirty or thirty-five) of delicate habits, with a peculiar softness of skin, and an obviously feeble capillary circulation on the surface, as shown by the facility with which the extremities are chilled and the complexion rendered pale or livid by cold—most remarkably in those whose parents or ancestors have been simi- larly affected—in those who have been imperfectly nourished in early youth, and who have been subjected, at that period of life, to other permanently debilitating causes, to impure air, deficient exercise, and long-continued applications of cold and moisture—and in those who have recently suffered from some peculiarly debilitating influence, such as mental depression, febrile disease, particularly the contagious febrile diseases, or the incautious use of strong remedies, such as mer- cury. In such persons it affects peculiarly the nostrils and upper lip, the eyes, the lymphatic glands in all parts, and the joints or extremities of the bones in childhood, and the lungs in more advanced life, appearing however very frequently in other parts, both external and internal. But the essential peculiarities of scrofulous inflammation (as distinguished from healthy) show themselves in the effects to which it leads, particularly in the fol- lowing results:—1. In external parts; in slow suppuration, distinguished by the formation of a thin or watery pus, containing fragments of the consistence of soft cheese or lard. 2. In this suppuration, very frequently degenerating into languid and intractable ulceration. 3. In internal parts; in the rapid deposition of the small roundish granular bodies, to which the name of tubercles is now very 94 inflammation, (Varieties and Complications.) generally restricted, and which are often the prelude to the unhealthy forms of suppuration and ulceration just mentioned. It has been much disputed, indeed, whether tubercles are, in any case, a pro- duct of inflammation; and it must be allowed, 1. That they are often found to have been deposited in parts where there has been no previous indication of inflammation, or even of congestion of blood; and, 2. That even in a constitu- tion where there are extensive tubercular deposites, inflammation may produce its usual effects, and wounds heal by granulation, of the usual appearance. From this last fact it is plain, that inflammation of a certain degree of intensity, even in a scrofulous habit, will produce effusion of coagulable and organizable lymph. It is certain, also, that tubercular matter once deposited from the blood-vessels is never organized like the exudations of lymph; and, according to Gendrin, the decolourized globules of blood, which may be recognised in strictly inflammatory exudations, are not perceptible in them. A specific distinction, therefore, ob- viously exists between the results of healthy inflammation and tubercular deposi- tion. But when it is remembered, that the deposition of tubercles may pretty certainly be determined by long-continued mechanical irritation;—that in cases where they are found to have been deposited rapidly, and in great numbers, and therefore have been quickly fatal, the causes exciting, and the symptoms, gene- ral and local, attending the disease, are found to have been almost precisely those of inflammation of the same parts;—when it is remembered, also, that scrofulous tubercles in their incipient stage are found not only intermixed with, but graduating by insensible degrees into, the usual inflammatory exudations:— and that, in their advanced stage, in children (where their progress is more rapid than in adults) they may often be found softening and suppurating precisely in the same manner as the lymph thrown out by inflammation—it can hardly be doubted that the process by which tubercles are formed in the different textures ought to be regarded, in many instances, as a form or modification of inflamma- tion. The fact seems to be, that when the blood is in a peculiar and unhealthy con- dition, the result of the remote causes of scrofula, when its vitality is deficient and probably its fibrin deficient—when its motion is languid in the small capilla- ries, particularly in those parts of the body where the capillary circulation is necessarily slow, as at the apex of the lung and in the lymphatic glands—partial exudations of its albuminous portions are very apt to occur (just as extravasations of blood, of which the fibrin has been artificially abstracted, or deprived of its coagulating power, in the experiments of Magendie, are found so readilv to take place;)—that these albuminous exudations, not possessed of the vitality which is requisite for forming a cellular tissue, or becoming organized, cohere into minute spherical masses, as happens to any fluid of a similar consistence spread out in thin films on any surface, and thus give origin to tubercles, which afterwards grow by attracting the same materials out of the blood-vessels: and that this ex- udation, although not absolutely dependent on, is, much promoted by, congestion of blood, or inflammation, of a low degree of intensity, in the parts where it takes place.* All the facts connected with tubercular deposition and in its connexion with inflammatory effusion, seem to depend on the principle, that the fibrin of the blood is deficient in vitality, i. e. deficient in those properties which it posseses only during its residence within a living body; in consequence whereof it readily escapes from the small blood-vessels (in which we know that it is retained very much by its own vital properties,) and when it has escaped assumes the forms which the gravitation of its particles, in the absence of peculiar vital attractions, * That a peculiarity in the vital constitution of the blood is essentially concerned in the production of tubercles, appears most distinctly from this, that tubercles may sometimes be distinctly perceived in the discoloumed coagula found nfter death in the heart and large vrs- •els of scrofulous subjects. inflammation, (/ ar'uties and Complications.) 95 determines; that, under the influence of a slight or chronic inflammation, causing congestion and relaxation of the small blood-vessels, this kind of extravasation will be peculiarly apt to occur; but that, under a stronger excitement, a more in- tense inflammation may be excited in which the same blood may participate, and in which its fibrin may be both augmented in quantity, and have its vital proper- ties so heightened, as to furnish the same products as are seen in the inflamma- tion of a healthy constitution. Scrofulous tubercles have been likened by some to parasitic animals, and others have denied that they undergo any vital changes after they have been once deposited, supposing them to be then merely foreign particles, which are broken down and carried off by the purulent matter effused from the vessels of the living textures around them: and it is certain that they do not themselves contain blood- vessels; that the part3 in which they are deposited become gradually nearly void of blood, and the vessels supplying them obstructed; and it is doubtful whether the whole of a tubercle, once deposited, is ever taken up again into the circula- tion. But they certainly often undergo two changes, which may be strictly called vital: in more acute cases many of them soften and break down (in like manner as the lymph effused from healthy inflammation in cases of abscess does,) gene- rally into an irregular and unequal purulent matter; but, in the case of children, often into pus of pretty healthy appearance; and in more chronic cases, when the constitution has not so much suffered, they gradually harden into inert masses, often ultimately into earthy concretions, by the absorption of their softer parts. The growth and the unhealthy suppuration of scrofulous tubercles as well as other cases of scrofulous inflammation and its consequences, are attended by symptoms, both local and constitutional, evidently akin to those of healthy in- flammation of the same parts, but differing from them in being less violent and more chronic and intractible, the pulse usually more frequent and softer than in inflammation, and the fever taking more surely the form of long-continued healthy hectic. 2. The Erythematic inflammation is another well-marked modification of the process which has been described as simple or healthy inflammation. The pecu- liarities of this form are, 1. The tendency to spread much more rapidly and ex- tensively along the surface in which it commences, and, 2. The much less ten- dency to effusion of coagulable lymph, and the total absence of the plastic quality, or power of becoming organized in the effusions. On the skin the- matter effused is in general serum only, but in the sub-cutaneous cellular membrane, and in serous membranes (which are unquestionably liable to this form of inflammation,) a fluid more or less distinctly purulent, although never bounded by deposites of concrete lymph, is often poured out in very large quantity. This form of inflammation often occurs in the sub-acute degree, attended with little fever; and the term Erythema is then properly applied. But in the more violent cases there is much fever, attended with two striking peculiarities, 1. That it begins sometimes before the inflammation shows itself—sometimes three days sooner; and, 2. That it may be intense and dangerous when the inflamma- tion is slight, and has very frequently more of typhoid character than that which attends the healthy inflammation of the same parts, i. e. the pulse is softer, or more easily reduced in strength by evacuations, the tongue is drier, and there is more evidence of deficiency of secretions, the voluntary muscles are more en- feebled, and there is more delirium or tendency to stupor. To such cases of erythematic inflammation the term Erysipelas is properly applied; and they evi- dently belong to the same class of diseases as the contagious exanthemata. In such cases the erysipelatous inflammation often tends to sloughing or gan- grene, particularly in the cellular substance, where it may exist independently of any erythema on the skin, and has been described under the name of the diffuse in- flammation. This tendency of the inflammation is obviously given by the typhoid 96 inflammation, (Varieties and Complications.) nature of the fever attending it, and which often implies great danger, altogether independent of the extent, or of any effects, of the local inflammation. The tendency to erythematic inflammation exists in some individuals more than others; but in many cases it is obviously given, not by internal constitution, but by some hitherto imperfectly understood external cause, which is obviously of local and temporary operation; because at certain times and in certain districts, it prevails much more extensively than at others. The disease is certainly capable of being transmitted from one person to another by inoculation, and is certainly propagated in many cases by contagion, which is in fact, as to it, nearly the same thing as inoculation, because it is almost exclusively in those persons in whom there has been some wound or irritation of the surface, that the con- tagious effluvia apparently arising from others affected with the disease take effect. But in this, as in other cases of diseases which become epidemic, although we are sure of contagion (i. e. of intercourse with persons already affected,) being one cause of the extension, we have reason to believe that it can- not be the sole cause. The erysipelatous inflammation and accompanying fever is certainly more apt to occur in confined and ill-aired situations than in others; and its specific cause is certainly often developed in hospitals, or attaches itself peculiarly to them. The same form of inflammation is often seen, at the same time, and in the same persons, to affect the mucous membranes of the nose, mouth, throat, and larynx, or even to spread from the face inwards to these parts, or vice versa. It not only affects, as already stated, the cellular membrane frequently and exten- sively, but occasionally the fibrous membranes, as the pericranium. From the frequency of inflammation of the veins in connexion with the diffuse inflamma- tion of the cellular membrane, it may be presumed that their lining membrane is liable to the same form of inflammation. And there is good evidence that the peritoneum frequently, and the serous membranes of the thorax occasionally, take on inflammation presenting very nearly the same characters as erysipelas of the skin, tending to the effusion of a bloody serum, mixed with a little purulent matter, of a whitish milky fluid or of a more perfect pus, but with little or no exudation of plastic lymph; that such cases are occasionally epidemic; that they may be observed to be in connexion with external erysipelas; that thev are attended with great depression of the circulation, and are litde under the power of depleting remedies; and that the danger of the disease, in the worst cases of the kind, is so little dependent on the extent or intensity of the inflam- mation, that in the cases most rapidly fatal the least amount of inflammatory exudation is found on dissection. The most remarkable case of this kind is the Puerperal fever, which is cer- tainly often communicated by the medical attendant of lving-in women; but a precisely similar form of peritoneal inflammation certainly exists and even spreads epidemically in some instances, independently of parturition. Again, the animal poison which is frequently developed in dead human bodies, before putrefaction has made any progress, excites inflammation of the same diffuse or erythematic character, and fever which is often typhoid, and so completely independent of the local inflammation as its cause, that it has been known to hie fatal when no inflammation was perceptible; and is very generally most dan- gerous, when the inflammation at the puncture where the poison has been in- troduced is slight, and when the diffuse inflammation commences at a distant point, i. e. at the axilla in the case of a puncture in the finger. As to all these forms of erythematic inflammation it is to be ohserved, that there is a great difference in individual cases; the inflammation is sometimes intense, the fever attending is high, the pulse firm, evacuations well borne, and the local effects of the inflammation, if not controlled by remedies, dan- gerous; but, in other cases, the inflammation is comparatively slight, its local effects inconsiderable, and the fever attending it typhoid, and evidently a^gra- inflammation, (Varieties and Complications.) 97 vated by much evacuation. And in this, as in other instances of epidemic febrile diseases, these differences are seen, not only in individual cases, but in the pre- vailing or average character of the cases occurring in the different places or at different times. The effect excited in the human body by the poison of glanders in the horse, afford another example of the introduction of a poison exciting inflam- mation of a peculiar or specific character, singularly different in its progress in the human body from what is observed in the horse, inasmuch as its progress is much more rapid, and its termination in gangrene almost uniform. 3. Nearly allied to these examples of specific inflammation are the character- istic effects produced on the skin, and generally upon certain internal mucous membranes, by those animal poisons which produce the febrile and contagious exanthemata—plague, small-pox, chicken-pox, measles, scarlatina, and likewise a large proportion, and the most characteristic examples, of the common contagious continued fever or typhus. In all these the true skin is partially inflamed, and the cuticle at the parts affected is sooner or later separated and detached, showing that there had been not only congestion of blood in the affected parts of the skin, but al- teration of their usual secretion; but there is a wide difference in the appearance, pro- gress, and effects, of this inflammation, by which these diseases are easily distin- guished from one another. In all these diseases, known in this country, the mucous membrane of the fauces is more or less peculiarly inflamed; in the small-pox and measles the mucous membrane of the lungs; in scarlatina that of the nostrils, and the lymphatic glands in the neighbourhood of the tonsils, which often ulcerate and slough; and in the measles the mucous membrane of the intestines is very often also inflamed, and that of the eyes and nostrils uniformly. The inflammations of the internal membranes have not the same specific peculiarities of appearance as those of the skin. But of all these, as well as of erysipelas, it is certain that these different inflammations are not the cause of the fever which attends them, being uniformly of later date than the febrile symptoms; that they differ some- what in character from, and run their course in a more definite time than, the healthy inflammations of the same parts; and that they constitute, in many cases, but little of the danger of the diseases in which they occur; but that, in some cases, they are more intense, approach more to healthy inflammation of the same parts, constitute a greater part of the danger, and admit of more active treatment than in others. In all these cases it is certain that a peculiar poison circulates in the blood, generally absorbed from without—in the case of the typhus fever, probably, some- times generated in the body itself—and the peculiar or specific agency of this poison in exciting inflammation at particular parts is so far illustrated by the known effect of mineral poisons, as arsenic or mureury, or various vegetable matters, as jalap, scammony, savine, &c. taken into the blood, in exciting inflam- mation on particular portions of the internal mucous membranes (and in the case of mercury and arsenic on the skin likewise)—or of various poisons, animal and vegetable, in producing urticaria or analogous eruptions. But, in the case of the stricdy morbific poisons, two striking and peculiar phenomena are observed—1. That, after the poison is introduced, it lies latent for a time, often a long time, before it excites either fever or inflammation; or as it has been recently expressed, it has a period of incubation. 2. That, after it has produced its full effect on the system, not only the products of the inflammation at the parts affected, but other excretions from the blood, and perhaps the blood itself, have the same power as the poison originally introduced, of exciting, or of propagating, the disease in others; so that the poison has in some hitherto mysterious manner been " multiplied in the mass of blood" before producing its specific effect. Two other facts may be stated, as equally well ascertained, in regard to the process to which these morbific matters are subjected in the living body—1. That in certain circumstances, not vet fully understood, instead of being multiplied in the blood, and producing their effects on the body, they are probably decom- Vol. I.—13 98 infammation, (Varieties and Complications.) posed, and certainly expelled from the body, and are innocuous; and, 2. That any living body, in which any one of these has once produced its full effect, is thereby rendered nearly insusceptible of the same changes in future, and may, in general, absorb the same poison to aHy extent afterwards, without suffering any multiplication of it within itself. 4. On the surface of the body, inflammation certainly occurs in a greater variety of peculiar or specific forms than in internal parts. Almost all the cutaneous dis- eases, the mere erythemata, the papular, the scaly, the vesicular, the pustular, and the tubercular, are the effects of inflammatory actions on the skin. The pain, heat, and redness, are in many of these of short duration, in comparison of the other appearances to which these specific inflammations lead, and by which they are re- cognised : but cases occur of all these forms of cutaneous disease, in which the inflammation of their first stages is well-marked and intense, and obviously mode- rated with great advantage to the patient by the ordinary antiphlogistic remedies. The same general observation may be made on that peculiar or specific inflam- mation of the sub-cutaneous cellular membrane, distinguished by numerous small circumscribed collections of pus, forming within a single inflamed spot, and going on very certainly to sloughing of the interposed portions of the cellular substance, to which the term carbuncle has been applied; and likewise on certain peculiar or specific inflammations of the mucous membrane of the mouth or fauces, seen chiefly in children, or occurring symptomatically in adults; the aphthae, that particular af- fection to which the name of diphtherite has been given, which is occasionally epi- demic, and when it extends into the larynx is very generally fatal; and that much more rapid and malignant form of inflammation, going on quickly to ulceration and wide-spreading gangrene, which has been described under the name of the can- crum oris. There is reason to believe that the inflammation of the mucous membrane of the great intestines which characterizes dysentery, when it prevails epidemically (and pretty certainly spreads sometimes by contagion,) is in like manner specific; and, because specific, is attended with more depression and danger, and is less under the influence of remedies, than simple inflammation of the same parts: and it is still doubtful, whether the inflammation and ulceration of the mucous membrane, espe- cially of the clusters of mucous glands, of the intestines, which are so common, and have attracted so much attention of late years, (both in continued fever, espe- cially if of long continuance, and in hectic fever,) are to be regarded as specific in- flammations, or how far they are the effect of the usual contents of the intestines, and especially the excretions which pass off through them, acting on a mucous membrane, which in consequence of the previous disease is nearly divested of its protecting mucus. 5. There are still three other forms of disease, properly called inflammatory, both on account of their first symptoms and of their characteristic results, but which are likewise strictly specific inflammations, viz. the rheumatic, the gouty, and the syphilitic inflammation. The first of these is distinguished by the number of textures which it affects in different or even in the same individuals, the fibrous or synovial membranes, the sheaths of the muscles, perhaps the muscles themselves, the neurilema investing the nerves, often portions of the bones (in cases of nodositv of the joints,) and fre- quently also both the pericardium and the internal fining membrane of the heart, and great arteries. It is distinguished, also, by the rapfdity with which it shifts, either from one part of the body, or from one of these textures, to another; and farther, by never tending to suppuration, ulceration, or gancrene. Indeed, there are many cases of rheumatic pains, in which we must admit that the existence of inflammation is not shown by the characteristic effusions on any texture • but when we have opportunities of observing its effects on the synovial membranes some- times on the ligaments of the joints—on the bones, and on the heart, in the dead body—or when we observe the symptoms, and the effect of remedies on acute cases of the disease in the living body, we cannot doubt of its being correctly inflammation, (Varieties and complications.) 99 classed with the inflammations. It seems probable that there is some peculiarity in the condition of the blood, which disposes to this form of inflammation, rather than others, on the application of cold or wet; and it is certain that, in cases of acute rheumatism, the buffy coat seen on the blood is usually remarkably thick; and that, in the rheumatic pericarditis, the effused matter is more solid than in other cases where the same membrane is inflamed. How such peculiarity may be produced is quite uncertain; it has not been distinctly traced to any peculiarity of diet or mode of life, and it is certainly not communicable from one individual to another. We have rather more information, although by no means precise knowledge, as to the peculiarities of the Gouty inflammation, which occurs only after the age of puberty and seldom in youth, which affects only a few joints in one paroxysm, and generally the small joints in the extremities—which is always preceded by a disor- dered state of the stomach; and, when it recedes suddenly, is very generally fol- lowed by a violent affection of the stomach, sometimes apparently a metastasis of the inflammation, often rather a gastric neuralgia. This is a form of inflam- mation to which only a portion of mankind are in any circumstances liable; its occurrence in them seems to depend very much on hereditary predisposition, and very much on plethora, especially if induced by the use of fermented liquors. We know that it is much connected with the gravelly deposites in the urine; and that, in severe and protracted cases, it leads not to suppuration or gangrene, but to the depo- sition of concretions, consisting, in a great measure, of lithic acid. The existence of a peculiar ingredient in the blood, determining various morbid changes and a peculiar form of inflammation, seems here sufficiently indicated. The symptoms of Syphilis proceed always from a peculiar or specific poison, which may be introduced into the blood in various ways, and excites diseased ac- tion, always inflammatory in the first instance, with these curious peculiarities: 1. That it affects certain organs only, the skin of the genital organs peculiarly, but the skin generally, the lymphatic glands, chiefly, however, in the groin, the mu- cous membrane of the fauces, the iris of the eye, and the periosteum and bones, at the parts where these are most dense. 2. That it is every where, when un- complicated, of chronic character, but leads to different consequences in different parts; in the skin of the genitals very certainly to ulceration; on the skin gene- rally to various exudations, perhaps most generally scaly, and often subsequently to ulceration; in the lymphatic glands to suppuration, and then to ulceration; on the iris to simple effusion of lymph; in the bones, first'to increased deposition, and afterwards to irregular absorption and caries. 3. That it is often combined with, or passes into, simple acute inflammation of the same parts, (especially under excitement,) or scrofulous inflammation. 4. That even independently of such com- bination, there are many varieties in the appearance and progress of the affections, contracted by impure sexual intercourse, such as those indicated by the terms scaly, pustular, vincular or tubercular venereal disease; but whether these varie- ties are to be ascribed to different specific poisons, or rather to peculiarities of con- stitution, is doubtful. The inflammation exhibited by the poison of gonorrhoea, whether in the ure- thra or on the eye, is clearly specific and often very acute, rapidly extending along the membrane, causing great swelling and copious purulent effusion, but no ten- dency to ulceration or sloughing, except when it affects the cornea. The specific nature of the inflammation, both of syphilis and gonorrhoea, is clearly shown by the power of the inflammatory effusions to excite the same dis- ease if applied to certain parts (the genitals, the mouth, the eyes, or any abraded surface) in other persons. What has been said of the specific distinctions among inflammations, is per- fectly illustrated by observing the varieties of inflammation in the eye—the devia- tions from the most usual and simplest form there seen—in the purulent Egyptian, or gonorrhoeal contagious opthalmia—in the rheumatic and usually remittent oph- thalmia—in the obstinate strumous ophthalmia, tending to the formation of pus- tules, which in their commencement often exactly resemble incipient tubercles— 100 inflammation, (Varieties and Complications.) and in the syphilitic ophthalmia, attaching itself to the iris. Yet there is quite enough of common character in all these affections to justify our ranking them all as truly inflammatory; and all, in their incipient stage, admit of more or less relief from similar treatment. Besides attending to these cases, where the specific inflammation is an essential and characteristic part of the disease, it is of great importance to attend to those forms of inflammation which are often called symptomatic, occurring accidentally in the course of other diseases, and modified by their presence. Of this the most remarkable is given by continued typhoid Fevers, because it is quite certain that, besides the slight and evanescent cutaneous inflammation which very frequently attends that disease, various internal inflammations very frequently co-exist with it, sometimes from the commencement and in consequence of the application of cold before the attack of the disease, often arising in the course of the disease; and that the combination of these local inflammatory affections with the general fevers, forms a part of the danger of many individual cases. The seat of these inflammations is various. Judging from the symptoms, we should suppose that a degree of inflammation of the brain or its membranes was common, and a certain amount of serous effusion, which is often ascribed to inflammation, is very often found on the surfaces of the pia mater after death; but it must be allowed that any unequivocal marks of inflammation within the cranium after death from fevers, at least in Scotland and Ireland, are very rare. In the chest and abdomen, the parts most generally affected with inflammation during the course of fever are the mu- cous membranes and the substance of the lungs, and the serous membranes are almost uniformly exempt from it. Of the frequent existence of inflammation of the mucous membranes in the course of fever no doubt can be entertained, from the increase and alteration of their secretions, and in the abdomen from the partial thickening, softening and ul- ceration, with or without sloughing, of that membrane, which is frequently seen. There is more difficulty in distinguishing the effects of inflammation of the sub- stance of the lungs, combined with fever, from that condensation and softening of portions of the lungs, which is a combined effect of a fluid state of the blood, and of gravitation acting on the blood in the very feeble state of the circulation before death, as well as after death, (constituting the peripneumonie des aejonisans of Laennec.) But as condensation and softening of portions of the lungs after death from fever is not unfrequently observed in situations where no congestion could be determined by gravitation, we cannot hesitate to regard them as some- times effects of inflammatory action; and on the same grounds we may say that inflammation occurs occasionally, during fever, in the spleen and in the kidneys, hardly ever in other viscera, if we are careful to distinguish those latent inflamma- tions which occasionally supervene immediately on the decline of fever, from the phenomena presented during the continuance of the stricdy febrile or typhoid state. The cellular membrane, especially in the neighbourhood of the parotid glands, is often the seat of inflammation from unknown causes in the last stage of fever, the tunica conjunctiva of the eyes often inflames and sometimes partially ulcerates, and the skin of the parts which sustain pressure in the course of the disease is very prone to inflammation. But in all these cases' the inflammation is undoubtedly modified during the con- tinuance of the morbid actions peculiar to fever ; and the essential difference from the healthy form of inflammation is, that the effusions of decolourized coagulable lymph and of pus hardly ever takes place, the inflammation tending only to in- creased effusion in the mucous membranes, to thickening and softening, (ramollis- sement pultacee,) to ulceration, and to gangrene. The formation of healthy pus in abscesses in the cellular membrane is always justly regarded as a sign (although not as a cause) of the decline of the strictly typhoid state. That this modification of the process of inflammation should take place in the inflammation, (Modes of Fatal Terminations.) 101 case of typhoid fever, is what we might expect, from what we know of the differ- ence between the condition of the blood in that state of the body and in the simply inflammatory diseases, the phlegmasia? of Cullen. And the same general observa- tion applies to those cases of the contagious exanthemata—small-pox, measles, scarlatina, even erysipelas, in which the symptoms are most distinctly typhoid. The inflammation of the bronchia?, which uniformly occurs in Hooping-cough, and likewise in Asthma, is so far modified by the presence of these spasmo- dic diseases, as to be less under the power of remedies than in other cases, and likewise to lead more surely in some cases to the emphysematous state of the lungs, which implies more permanent dyspnoea; and the production of which in the con- stricted state of the bronchia?, during the fits of coughing in these diseases, is easily understood. Again, inflammation often takes place from accidental causes in the course of chronic diseases, implying a very feeble state of the capillary circulation, particu- larly in Dropsy and in Palsy, and is often so modified as to have the peculiar ten- dency, already noticed, to gangrene. In the course of strictly Scrofulous diseases, " intercurrent" inflammation is very common; sometimes probably causing fresh deposition of tubercular mat- ter, in all cases so modified by the previously existing disease as to be peculiarly obstinate. Inflammation occurs also in combination with that peculiar state of the blood seen in Scurvy and in Purpura, and its results are modified by that condition. In some cases of purpura, inflammation has been observed to have its usual charac- ters, and even blood drawn from the arm to show the usual inflammatory ap- pearances ; but in other cases, of both diseases, inflammation appears obviously to tend to haemorrhages rather than to the usual and characteristic exudations. This observation may, indeed, be extended to various other chronic and consti- tutional diseases, such as the various forms of the encephaloid disease and the melanosis, as well as to scrofulous diseases; in which a disease apparently local in the first instance so contaminates the blood, that any other local inflammation that may be excited will tend to the deposition of matter of the peculiar character already ex- isting in the body; and thus inflammatory attacks become the means of extend- ing such malignant diseases over the body. " The following case," says Dr. Carswell, " is by no means rare; an individual has a tumour on the surface of the body, presenting the characters of one or more varieties of sarcoma, or cephaloma. He has an attack of pneumonia or pleurisy, or both, of which he dies in the course of a few days. On examining the diseased lung or pleura we find, instead of an effusion of serosity, coagulable lymph, or pus, that the lung is converted into a solid mass, resembling a section of fresh pork; it is in a state of scirrhus, and the pleura is studded with tumours com- posed of a similar kind of substance." (Illustrations of the Elementary Forms of Disease.) Modes of fatal termination of Inflammation.—Before proceeding to the treat- ment of inflammation, it is of great importance to lay down as precise principles as possible in regard to the different modes in which inflammation, in different parts of the body, may become dangerous or fatal. These modes of fatal termina- tion of inflammatory diseases ought to be clearly and steadily in the view of the prac- titioner who treats them. Our knowledge of physiology enables us perfectly to un- derstand how these are brought about, notwithstanding the imperfect state of our knowledge as to the process of inflammation itself 1. In certain cases, all that is necessary in order that inflammation may be fatal, is merely that it shall subsist a very few days, in an intense form, on certain parts of the body, producing there only its usual effusions, in no such quantity as mate- rially to alter any texture, or mechanically impede any of the functions of life; the constitutional fever which it excites is nevertheless attended with such extreme de- pression of the circulation, as to terminate quickly in death by syncope. This is 102 inflammation, (Modes of Fatal Terminations.) most remarkably seen in many cases of inflammation of the peritoneum; when the fatal event is preceded only by gradually increasing faintness, sickness, and vomiting, coldness of the extremities, cold sweats, and failing pulse, the breathing remaining unembarrassed, and the head perfectly clear, up to the moment of death, which can be ascribed only to sympathetic affection of the heart. But why the fatal depression of the heart's action should take place in some cases (as in the vio- lent inflammation immediately succeeding a perforation) within a few hours from the commencement of the disease, and when hardly a vestige of inflammatory ex- udation has taken place, and in other cases not until many pounds of lymph or pus have been effused, we have no means of judging. The majority of cases of fetal peritonitis are unattended with gangrene. The effect of the inflammation of this texture on the actions of the heart is clearly analogous to, and illustrated by, the sudden effect of a violent injury of the stomach or abdomen, causing extreme faintness or sudden death; and we ought probably to regard the very peculiar sickening pain existing in both cases as the cause, not the effect, of failure of the heart's action. Inflammation of the mucous membrane of the intestines, attended with diarrhoea or dysentery, is sometimes fatal in the first stage, when it has produced no other effect on the membrane than effusion of whitish lymph; this is especially so when it attacks a very debilitated subject, or when its extent on the membrane is greater than usual; and in such cases death takes place in the same manner as has been now described. And in those cases of inflammatory diarrhoea or dysentery, which run a longer course, and produce ulceration of the bowels, more or less of this pe- culiarly sedative effect on the circulation attends the disease and constitutes great part of its danger; and it has been, in part at least, owing to this cause that dys- entery was ranked by the older pathologists among putrid, rather than inflamma- tory diseases. The fatal effect of inflammations of other parts in the abdomen and pelvis, of the liver, spleen or pancreas, kidneys, bladder or uterus, and likewise of the larger joints, is often to be ascribed to the same principle, although the symptoms preceding it may be more complex, and more decided disorganization may ap- pear on dissection. For that disorganization is often not such as materially to impair any functions essential to life in the affected organs; the extent of the disorganization bears no fixed proportion to the depression of the vital powers attending it; and death often takes place before any exhausting process of suppu- ration or ulceration has been established. 2. In many cases, inflammation within the cranium (producing generally, in the first instance, not only pain, sickness, and delirium, but after a time slow or irregular pulse, spasms, or palsy) leads, even within a few days, to such conse- quences as we consider adequate to explain death in the way of coma, t. e. death preceded by stupor of some continuance, the heart's actions continuing vigor- ous almost to the last, but the respiration becoming imperfect as the insensibility increases, and ultimately, in the best marked cases of the kind, coming to a stand while the pulse is still distinct. We consider this kind of death sufficiently explained if we find any considerable portion of the brain or cerebellum either disorganized or compressed by effused fluids, because we know, that although the parts essentially concerned in respiration, and probably in sensation gene- rally, do not extend higher than the medulla oblongata, yet, both in experiments on animals and in observations on the human body, it is very generally found that disorganization or compression, though situated considerably above that part, greatly deranges or altogedier destroys all vistiges and effects of sensation in the body; and this the more certainly and effectually as they are more sudden- ly produced, and as they are so situated as to produce pressure downwards on the medulla. Such disorganization or compression may be readily produced by inflamma- tion, either by softening of portions of the brain, or by the formation of circum- scribed abcesses, or generally, in more chronic cases, by hardening, by effused inflammation, (Modes of Fatal Terminations.) 103 lymph, or by effusion of pus on the membranes, or by effusion of serum on the surface or into the ventricles of the brain—which last is indeed a very general accompaniment of any fatal inflammatory action within the cranium, and often appears as the only cause to which the fatal coma is to be ascribed. We know, indeed, that great serous effusions may take place gradually within the head, which are neither preceded by inflammation nor followed by coma; and we are not justified, probably, in any case in regarding it either as the effect of the one or the cause of the other, merely from the appearances on dissection. But if (as often happens) we have the same set of symptoms—those of the acute hydrocephalus, more or less rapidly succeeding one another—as we meet with in cases where not only serum, but pus and lymph are found on dissection —if we find after these, serum only to have been effused, but in such quantity, as if rapidly effused, must have caused much pressure on the brain—and if we know that the symptoms have been of short duration only, we cannot hesitate to regard that serous effusion also as a result of inflammatory action. The symptoms in such cases vary considerably, but may be said in general to be, in the first instance, those of inflammation within the cranium, according to the statement already made of the general symptoms of internal inflammations; but which are masked and obscured in the latter stages of the disease, by the stupor, with or without palsy or spasms, which are to be expected when the brain has been injured or compressed. There are a few cases of inflammation of the kidneys, generally of chronie character, which terminate in such disorganization as materially alters the com- position of the urine, very greatly diminishes the amount of the excretion, and thus produces, and satisfactorily explains, gradually increasing insensibility and death by coma, analogous to that which takes place in the eschuria renalis; and we can have no doubt but that many cases of hepatitis would be fatal in the same manner, were it not that the inflammation there is almost always partial, and leaves portions of the liver fit for their natural function. 3. There are many cases of inflammation in which the symptoms before death, and the appearances after it, clearly indicate and explain death by asphyxia, i. e from the access of air to the blood at the lungs being in some way or other mate- rially impeded. The most rapidly fatal cases of this kind are those in which the larynx is inflamed, leading either to effusion of lymph on the surface of its inner membrane (the preternatural membrane of croup,) or to effusion of serum or pus behind that membrane, or mere thickening of the membrane, just as the rima glottidis;—or where the cellular membrane surrounding the pharynx is so dis- tented, by effusion of pus into it, as to compress and nearly close the glottis. In such cases the ^he fatal termination is by strangulation rather than suffocation, and is indicated by the sonorous, long-continued, and difficult inspirations, with loss of voice, croupy cough, and often difficult deglutition increasing the cough and dyspnoea; and the whole symptoms are generally remarkably liable to spas- modic exacerpations. Another case in which death takes place by asphyxia, rather in the way of suffocation than of strangulation, and sometimes very rapidly, is that of bronehi- tis or pulmonary catarrh, or peripneumonia notha, i. e. of inflammation, thicken- ing and rapid increase of the mucous secretion of the lining membrane of the bronchia?. This assumes the form of the catarrh suffocant, and is rapidly fatal, sometimes even in strong habits, when it occurs more generally than usual, ex- tending to both lungs, and in all their lobes, to the minute branches of the bron- chia?; or more generally, when it takes place in a constitution previously much enfeebled, in which probably the inflammation is more apt to spread extensively over the bronchia? than in others, and in which the expectoration necessary for the relief of the patient is not easily established. Thus the acute bronchitis, oc- curring idiopathically, is often fatal in very young and very old persons; and it is still more frequently the immediate cause of death when it occurs sympatheti- cally, in the course of continued fevers, small-pox, measles, or hooping-cough. In 104 inflammation, (Modes of Fatal Terminations.) its chronic form the bronchitis is often complicated with, and increases the dan- ger of, a much greater variety of diseases. In this last disease, as well as in many idiopathic cases, the bronchitis is attended with a peculiar spasmodic cough, exacerbations of spasmodic dyspnoea, which however do not increase the danger so much in this disease as when the larynx is affected. That dyspnoea threatening a fatal event depends on bronchitis more than on other inflammations within the chest, may in general be easily enough ascertained by observing the absence of dulness on percussion, the generality of the bron- chial rales (especially the mucous andsub-crepitous,) the weezing sound of respi- ration, and the character of the expectoration. In many such cases the habitual spasmodic or asthmatic paroxysm, and the indications of the emphysema of the lungs, which is a frequent consequence of them, materially assist the diagnosis: but it is to be observed that the existence of habitual bronchitis and asthma does not by any means preclude the possibility of other inflammations within the chest. When the substance of the lungs is inflamed on both sides, the disease may be fatal before the effects have gone farther than the general effusion of serum into the bronchia? and cells; but this is a very rare case. The true peripneu- monia of one lung generally shows itself not only by fever, cough, dyspnoea, and more or less of pain; but by some physical symptoms confined to that side, and contrasting with the other; a degree of dulness on percussion, the crepitous rale, and afterwards the bronchial or suppressed respiration; but these indications are often much less distinct than those which attend the inflammation of the pleura, and of course can become distinct only when injury has already been done to the substance of the lungs. The " peripneumonic sputa," consisting of viscid trans- lucent mucus stained with the colouring matter of the blood, either of a reddish or brownish colour, or of a yellowish or greenish (which had given rise to the idea of a " billious pneumonia,") are a very characteristic mark when present; but may be absent throughout in cases which are perfectly well-marked, and when present, afford no evidence, either by their amount or duration, of the ex- tent or intensity of the inflammation that exists. Acute inflammation affecting the substance of the lung may go on in three days, and, if unchecked by remedies, does often go on in less than seven, to the peucliar condensation, partly consisting of decolourized lymph, called hepatisation; and if this change is rapidly effected, it may be a sufficient cause of death by dyspnoea, notwithstanding, that, in many cases of slower progress (chronic pneumonia, chronic pleurisy or phthisis,) a whole lung, or even the greater part of both lungs, may be rendered impervious to air without urgent dyspnoea, or death by asphyxia. But in cases of this last kind, not only is the whole quan- tity of blood in the body requiring to be arterialized at the lungs gradually very much diminished, but the distribution of the blood in the lungs is gradually ac- commodated to the new state of things; the vessels of the diseased part are choked up and deserted by the blood, and those of the sound parts are filled and ddated, as is clearly shown by injections after death; and it is partly because these changes cannot be rapidly effected, and partly also because a partial pneumonia is often attended by a more general bronchitis, that the respiration is so much, and often fatally, embarrassed by the inflammatory condensation of a part only of one lung. Acute pleurisy clearly indicates itself in general within a day or two from its beginning, not only by the fever and sharp pain of the side, but more unequivo- cally by the dull sound on percussion, the suppressed sound of respiration, and the imperfect movement of that side of the chest. But the cases of pleurisy which are uncombined with the peripneumonia are seldom the cause of death by rapidly increasing dyspnoea. When the inflammation has not been of such intensity as to extend inwards into the substance of the lungs, its progress is generally 6low, inflammation, (Modes of Fatal Termination.) 105 and although it may lead to very extensive effusion, and completely destroy the function of one lung, it is seldom fatal while the other lung remains free from disease; and experience shows that a very great amount of such pleuritic effusion may be gradually absorbed, and leave the lung confined and often diminished by the preternatural membrane, which is permanendy left, but in some degree fit for its function. Inflammation of the heart or pericardium, if rapidly fatal, is so more frequently in the way of asyhyxia than of syncope; for the obstacle opposed, whether by effusion in the pericardium, or by inflammatory exudation of unusual extent on its inner membrane on the left side (always the side chiefly affected,) to the flow of blood through the lungs, causes very generally much dyspna?a, and often in- duces either pneumonia, extensive bronchitis^ or serous effusion in the lungs. 4. In some cases, inflammation is fatal in a manner perfectly different from these, viz. by a part of the effusions Which it produces being taken into the cir- culation and acting as a poison, producing typhoid symptoms, and often inflam- mation and effusions of peculiar character in distant parts. It seems pretty cer- tain that a part at least of thi3 effeet of an animal poison, such as that communi- cated from dead bodies, must be ascribed to the peculiar inflammation excited at the point where it is introduced, and to a morbid matter being formed there, and then absorbed, and often exciting inflammation at different points on its way into the larger veins and the general errctilation. When circulating in the blood, it is certain, as already stated, that the poison excites a peculiar typhoid fever, in which the heart's action is rapidly depressed, which bears no fixed proportion to the extent or intensity of the inflammation attending it, and by which death may be effected without visible injury of any vital organs. Another case referable to the same head as that of inflammation of a vein, attended by the formation of inflammatory effusions, which are necessarily mixed with the circulating fluid ; and in which the fever soon takes the typhoid form, often attended with vomiting and diarrhoea, always with a peculiarly depressed state of the circulation, and a peculiar derangement of the nervous system, and is in like manner often fatal without visible lesion of any vital organs. This kind of termination is always to be apprehended where a vein is inflamed, but cer- tainly does not always take place ; and the reason of its not taking plaee in some cases (as in some of those inflammations of the femoral and iliaC veins which lead to the phlegmasia dolens) may probably be, that the only effusion from the inner surface of the inflamed vein in these cases may be of the nature of organiza- ble lymph, not purulent, and, therefore, not poisonous, although mixed with the blood. And it may be strongly suspected that the more rapidly fatal cases of inflammation of the veins are instances of erythematic and often contagious inflammation tending to purulent effusion only; some of them certainly producing no fibrinous incrustation on the inside of the vein affected. We know, from the experiments of Magendie and Gaspard, that pus injected into the veins of a living animal produces typhoid fever and death,' unless a criti- cal evacuation takes plaee, by which, after undergoing changes in the course of the circulation, it is probably expelled from the body; and, therefore, 'we cannot be surprised to find that similar results follow from pus being formed in a situa- tion in the living body in which it is inevitably mixed with the circulating blood. But we know farther, that the purulent matter of inflamed veins circulating in the blood often produces another effect, viz.- local and peculiar inflammation, and rapid deposition of purulent matter in distant parts—in the liver, lungs, eavities of joints, &c. (See particularly Arnott, in Med. Chirurg. Trans, vol. xviii.) From this last fact, and from the microscopical observations formerly quoted, which show that much purulent matter is found in the vessels of a suppurating part, without being effused there, we have a satisfactory explanation of the occur- rence, which is certainly frequent, of rapid depositions of pus (sometimes of tubercular matter) taking place in internal parts, soon after the amputation of limbs where extensive suppuration, or scrofulous disease, had been going on; and Vol. I.—14 106 inflammation, (Modes of Fatal Termination.) this especially when the wound has healed by the first intention. The suppura- ting surface would appear to have been the outlet, by which pus, formed at the diseased part, and taken back into the circulation, had previously found egress from the body; and when this is closed, the effect is the same as if pus had been formed within the organs of circulation themselves and produced its usual poison- ous effect, both on the system at large, and also on individual organs.* If the recent observations of Mr. Gulliver and others, on the existence of globules of pus in the blood, even in the early stages of inflammatory diseases, shall be con- firmed, they will give additional certainty and precision to this doctrine in pathology. 5. In many cases, the fatal effect of inflammation cannot be ascribed to the effect of the local disease, either in obstructing the function of any organ directly necessary to life, or in contaminating the blood, but is effected by gradual ex- haustion of the system during suppuration and ulceration or sloughing, by which a long-continued febrile state is kept up. There are often very debilitating dis- charges by sweating or diarrhoea, and the functions of digestion and nutrition are so much deranged, that the patient sinks emaciated and enfeebled, in a manner illus- trated by death from starvation rather than by any other kind of violent death. The death from inflammation going rapidly to gangrene is often much more quickly produced, but, according to what was already stated is hardly ever to be regarded as merely the effect of the inflammation. The death by gradual exhaustion is that chiefly to be apprehended in cases of inflammation of the surface of the body and of the extremities, uncomplicated either with the immediate effects of violent injuries or with other disease; and the danger attending chronic inflammation, or that which has gone on to exten- sive suppuration in many internal parts in the chest and abdomen, is of the same slow gradual kind. 6. The danger of inflammatory disease is often more indirect, depending on its either blending itself with, or gradually passing into, other kinds of diseased ac- tion. In the more strictly febrile and exanthematous diseases, as already men- tioned, inflammation occurs almost uniformly—as part of the specific character of each disease, on the skin, and on certain portions of mucous membranes; very often as an accidental complication; sometimes probably as an effect of the dis- ease, in different parts already noticed; and, although very generally of peculiar character, and never to be regarded as the sole danger, is very often concerned, more or less, in the fatal event. It is chiefly in consequence of such complica- tion that the mode of death in these diseases is remarkably various, sometimes approaching closely to that by coma, sometimes by asphyxia, &c. There is a similar frequent complication of inflammation with all kinds of chronic and par- ticularly organic diseases. Some of these diseases are merely the sequelae of acute healthy inflammation; others (as the most common organic changes of structure in the liver and kidneys, the cirrhosis of Laennec, and the granular dis- ease of Bright,) appear to originate in more chronic inflammation and gradual degeneration or perversion of the organized matter thence resulting, and are liable to aggravation or increase from any fresh inflammatory attacks; bearing, in fact, very nearly the same relation to inflammation that tubercular deposition does: and even when no such connexion can be traced between organic disease and inflam- mation, there is no difficulty in understanding that the combination of the two may be fatal, when either affection, existing separately, might have either sub- sided entirely or been comparatively innocent. This is continually illustrated when we see internal inflammation (although of distant parts) supervening on organic disease of the heart, lungs, liver, or kidneys, and very often quickly in- ducing the farther complication of dropsical effusions. For although these are specifically distinct from the extravasations which proceed directly from inflam- * The occurrence of jaundice without obvious disease of the liver, in many cases in which purulent matter may bo supposed to be mixed with the circul iting- blood is another indication of the hitherto unexplored changes produced in such cases on the constitution of the blood. inflammation, (Treatment.) 107 mation, yet it is quite certain that in some constitutions, especially those in which some organic disease and consequent impediment, either to the flow of the venous blood, or to the natural excretions, exist, attacks of inflammation, even of single organs, as the lungs or bronchia?, the liver, the kidneys, are very often the immediate cause of general dropsy; and that, soon after dropsy has made some progress, the symptoms of such inflammation often co-exist with it, and the remedies for inflammation may still be effectual, not only in relieving these symptoms, but in arresting the dropsical effusions, and promoting their re-ab- sorption. Outline of the treatment of Inflammation, particularly in internal parts.— We shall conclude this outline of the subject of inflammation by a general sketch of the most approved method of treatment; stating first the essential parts of the antiphlogistic treatment, by which inflammation, if early opposed, may in many cases be effectually subdued, and in all cases moderated or restrained; and afterwards the limitations and modifications of this kind of treatment, which are demanded by various contingencies in the course of inflammatory diseases. We speak first of the antiphlogistic treatment proper to be adopted, to a greater or less extent, in the early stage of all cases of simple or healthy inflammation, oc- curring in a sound constitution, and attended with more or less of constitutional fever. This kind of treatment consists of two parts, the antiphlogistic regimen and remedies. The object of the antiphlogistic regimen is simply to remove every excitement or irritation which may augment either the strength or frequency of the heart's. action, or promote the flow of blood towards the affected part; it being perfectly ascertained by experience, and indeed easily understood, whatever doubts we may entertain as to the rationale of inflammation, that when that state exists in a constitution otherwise healthy, it is aggravated by whatever promotes and accele- rates the flow of blood to the affected part. Hence the strict antiphlogistic regimen consists essentially of three parts, low diet, rest, and quietude. The abstraction, in the most urgent cases, of all solid aliments, in all cases, of animal food, and the denial of all fermented or spirituous liquors, imply a gradual diminution of the quantity of the blood, and the removal of stimuli, by which the heart's actions are obviously and strongly excited. The cessation of all vigorous or sustained muscular movement likewise removes a cause by which the circulation is obviously and often powerfully excited;* and the exclusion of all sudden and strong impressions on the organs of sense, se- cures the body against a set of irritating causes, which act primarily on the nervous system, but always more or less excite the vascular system likewise, and very frequendy, by preventing sleep, manifesdy aggravate the fever which is consequent on inflammation. With the same general intention, various more particular precautions are of importance in the mflammation of individual organs;—and in all cases, the re- moval of any exciting cause of inflammation which can be detected—the hori- zontal position and absolute rest of an inflamed limb to retard the afflux of blood to, and favour the reflux from, the part affected—the erect posture, when the head or any part of it is inflamed; the prohibition of all efforts of voice when the lungs or other organs of respiration are inflamed; the contact of soft substances only with inflamed portions of the surface; the injunction of darkness and silence * The effect of muscular exertion on the heart's action does not seem to be satisfactorily ex- plained by the mere acceleration of the flow towards the heart by the veins; and the idea recently stated by Mailer, that the contractions of the heart, although not excitable directly by the will, are liable to affection by those changes in the nervous system which attend ef- forts of volition acting on those voluntary muscles which have their nerves from the same branches as the heart, (as is undoubtedly the case in regard to the iris, not moveable by the will, but moving in concert with the recti muscles of the eye when strongly excited through the third pair,) is probably correct. 108 inflammation, (Treatment.) in inflammations of the eye and ear, &c. Under these precautions, the body in general, and the affected parts in particular, are placed in circumstances the most favourable to the gradual and spontaneous decline of inflammation. Of the antiphlogistic remedies, which next demand consideration in all cases of inflammation, the only one on which absolute reliance can be placed is blood- letting, and there is no other remedy for any other kind of diseased action which can be put in competition with this in efficacy or importance. The efficacy of blood-letting in lessening the extent and intensity, and often arresting the progress of inflammation, would appear to depend on two princi- ples, which it is important to consider separately, to which indeed the powers of all other and antiphlogistic remedies may be ascribed, first, that it Aveakens the heart's action; and secondly, that it causes a derivation of blood from the affected parts. In both ways it diminishes the quantity of living matter in which the peculiar changes comprised under the term inflammation are going on; and whatever be the precise nature of these changes, as it is certain that the blood is an agent essentially concerned in them, it is easy to understand that the greater the quantity of blood sent to the affected parts in a given time, the greater amount of these changes, and particularly the greater quantity of effusion from the ves- sels (with which we have seen that the danger of most inflammatory diseases is very much connected) will take place. 1. That the heart's action should be weakened by the abstraction of the stimu- lus, by which its motion is habitually excited and maintained, is quite in conformity with all that we see of the effect of loss of blood in the healthy state, and with the general doctrine of irritability as laid down by Haller. It is not necessary in every case of inflammatory disease, nor even in every case of such disease where the heart's action is morbidly excited, to resort to this remedy; because there are many such cases where the history of the disease which exists is well known, and no danger is to be apprehended from allowing the inflammation to run its course, under the proper regimen, and spontaneously decline; and there are many others, which are complex cases, and where the local inflammation is not to be regard- ed as the chief danger. But in all those cases where not only the heart's action is increased, the pulse morbidly frequent, or strong, or both; but where we are sa- tisfied that this increased action is connected with, or maintains and aggravates, a local inflammation, which, in some of the modes already considered, threatens the life of the patient, such blood-letting as may impair the power of the heart is the appropriate and effectual remedy; and in all cases occurring in patients be- yond the age of three or four (below which age leeches are to be regarded as a general evacuation,) the simple and effectual mode of blood-letting is^by vene- section. It is perfectly ascertained, however, that the effect of this remedy on the heart's action is by no means exclusively produced in the way above stated, by with- drawing a part of the stimulus of blood, habitually acting on the heart The dif- ference, daily observed, of the effect of blood-letting in the erect and the horizontal posture, clearly shows that the loss of blood may powerfully effect the heart through the intervention of the central portions of the nervous system, probably of the medulla oblongata especially, although in common language, we speak of this effect being produced through the brain. The proof of this is, that when blood is drawn in the erect posture, so that the influence of gravitation co-operates with that of the operation in weakening the flow of blood to the head, not only are the sensations and consciousness of the patient, /. e. the functions of the brain and medulla oblongata, much sooner affected, but the heart's own action is much sooner impaired, than when the same quantity is taken from a patient lying hori- zontally. A most remarkable diminution of the frequency of the pulsations is thus very frequently effected, the pulse falling, for example, from 120 to 60 in a minute, at the same time that faintness and transient insensibility are produced. This plainly implies that the sudden diminution of the pressure of the circulating blood on the brain and medulla oblongata has acted or re-acted on the heart—in inflammation, (Treatment.) 109 a way perfectly illustrated by many other facts; by the failure of the heart's action, often seen to have been produced by taking off the pressure of depressed bone, or effused blood, or effused serum, (as in tapping hydrocephalic children,) to which the brain had previously been accustomed;—by drawing off the serum of ascites, and so diminishing the pressure on the branches of the abdominal aorta, promoting the flow there, and proportionally lessening that towards the head— or more simply by merely assuming the erect posture suddenly after long stoop- ing. The decided impression made on the heart's action in all these cases by sudden diminution of the pressure of the blood on the brain and medulla oblon- gata, is, in fact, very analogous to that produced by a sudden concussion, in cases of injury, or sudden increase of the pressure on these parts, in experiments on ani- mals. This sudden and peculiar effect of blood-letting on the heart's action being pro- duced through the intervention of the nervous system, is of course liable to modi- fication from the condition of that part of the Uving body; and it is a just and im- portant observation of Dr. Marshall Hall, that the effect of blood-letting in the erect posture, may be used as a test of the cases in which the full use of the remedy is likely to be important; because, in many diseases, not strictly or solely inflamma- tory, but apparently demanding loss of blood, e. g. in many neuralgic cases, and more remarkably in the beginning of continued fever, when large blood-letting is likely to be injurious, faintness is very easily produced in this way; whereas, in strictly inflammatory cases, really requiring much loss of blood, a large quantity may usually be taken in the erect posture without faintness. It is not, however, to be inferred from this, that blood should always be taken in the erect posture. The effect of the impression communicated to the heart through the nervous system is certainly not so permanent as that which is produced simply by the abstraction of the vital stimulus; and some persons, even under strictly inflammatory disease, become faint from the loss of blood in the erect posture, before as much is taken as can produce a permanent effect on their disease; and it may therefore often be advisable, when the existence of inflammation of healthy character is clearly as- certained, to bleed with precaution, rather to retard or prevent, than encourage, the approach of fainting. 2. The effect of blood-letting in causing derivation from parts actually inflamed to other parts of the body has not been studied with so much care as might have been expected from the pains bestowed on it by Haller. Whether this effect is, as he thought he had ascertained, inexplicable on merely mechanical principles, or whether as Magendie and Poiseuille assert, it is merely the effect of the contractile power of the vessels, and the forced state of distention in which they exist during life, causing a flow to any point where an opening is made, it is quite certain that a movement in that direction is immediately perceived in all the small vessels which can be brought under the field of the microscope, on a puncture being made in any one of them; and, in Haller's observations, it distinctly appeared that this movement often inverted the natural course of the circulation, and often extended to portions of blood which were stagnating in vessels, and caused globules to sepa- rate and become distinct which had previously combined into irregular masses. This being so, it cannot be doubted that similar changes must be effected, in a greater or less degree, in the blood stagnating in inflamed parts, when an exit is given to the blood from other parts of the circulating system, whether by general or local blood-letting. And it does not seem possible to understand on what other principle than this, blood-letting can be useful, as it undoubtedly is in certain cases of inflammation, chiefly abdominal, when the pulse is smaller and even feebler than natural, but becomes fuller and stronger; or in others (chiefly of the head, sometimes of the abdomen likewise) when it is slower than natural, small and sharp, and becomes more frequent and fuller after the evacuation. It may be supposed that the chief effect of local blood-letting is in general of this last kind, and that the chief effect of general blood-letting is on the heart's action; and it is certain that local blood-letting by cupping or leeches, is often ef- 110 inflammation, (Treatment.) fectual in those inflammations, generally of sub-acute character, which are unat- tended with disturbance of the general circulation; and that it is in cases of well- marked local inflammation, attended and supported by general fever, that the power of general blood-letting is most distinctly seen. In such cases, however, the local remedy is very generaDy found, after the force of the inflammatory fever has been somewhat broken, a most useful auxiliary to the other. No proposition in medical science is more certain than, and hardly any one is so practically important as, that which regards the power of large and repeated blood-letting to arrest the progress of inflammation in its early stage, before any great amount of effusion has taken place—and to cause many cases of it to ter- minate favourably by resolution, with such slight effusions only as is afterwards easily absorbed: which would otherwise have gone on to extensive and probably fatal disorganization of the different kinds above-mentioned. Indeed, it has been stated, and probably with truth, in relation to healthy inflammation occurring in a sound constitution, and unattended with mechanical injury to the parts concerned, that " every constitution which is capable of having such inflammation excited in it, is capable also of bearing the evacuations, chiefly of blood, by which that in- flammation may be subdued." (Bateman.) When so much confidence is expressed in the efficacy of this remedy, two ob- jections naturally present themselves:—1. How does it happen that some practi- tioners and teachers of medicine express themselves so doubtfully as to its useful- ness, even in diseases distinctly inflammatory, and place more confidence in re- medies which are here stated as of very subordinate importance 1 2. If so effectual a remedy for inflammation exists, how does it happen that so great a portion of the mortality in all parts of the world depends on inflammatory diseases] To the first objection, the proper answer is, that many medical men of high and deserved eminence have few opportunities of witnessing and estimating the effects of the remedy in the early stage of violent inflammatory diseases. A physician whose practice lies chiefly among the higher ranks of society in a great town—a consulting physician, who is called in by judicious and weU-informed general prac- titioners, only in cases of unusual difficulty, and generally of some standing—a hospital physician, who sees the diseases of the poor only in that advanced stage where they are willing to leave home, (particularly if there are well-conducted dispensaries in the neighbourhood)—has few opportunities of judging of the power of blood-letting over the symptoms of inflammation, general and local, if employed within forty-eight hours after a sudden and violent attack in a healthy constitution. It has often happened to the writer, to meet with more opportunities of observing and pointing out to pupils, the power of blood-letting over inflammatory disease in a single forenoon of visitation of dispensary patients, than in a three months' course of clinical instruction in a hospital. There, although inflammatory diseases are often seen, they are very frequentiy in those circumstances, either as to the stage of their progress, or as to complication, in which, if recovery can take place, it must be chiefly the work of nature, and often incomplete. To the second objection, what has now been stated as to the period of inflammatory disease at which pa- tients come under treatment, is of itself almost a sufficient answer; but a farther and still more satisfactory answer is to be found in what has been already stated as to the frequent deflection of inflammatory disease from the simple and healthy type, on which blood-letting exerts its most beneficial effect, and on its frequent complication with other diseased states, either immediately preceding it or accom- panying it, and altering and augmenting the danger to be expected from it. The abatement of all the most urgent symptoms of inflammation produced by blood-letting is often very striking. The relief to dyspnoea and to palpitation, if either of these forms part of the symptoms of the disease, is in general the most immediate, and is that which it is most important to observe at the very time of the operation; because if not effected then, it is hardly to be expected afterwards. The relief to pain, especially in the head, is likewise often very rapid, but in other cases taking place more gradually, and is nevertheless equally complete within a inflammation, (Treatment.) Ill few hours after the operation: many other uneasy feelings—heat, restlessness, thirst, anxiety, are often speedily relieved. But the advantage which is chiefly looked for, and regarded as the most decisive and the best security for all others, is that which is effected on the state of the pulse; and the change which is chiefly to be hoped for in it is, that it should become softer or more compressible. If it at the same time becomes less frequent, the advantage is more decided, but there are many cases, particularly in feeble subjects, where blood-letting is used with good effect, although the pulse, for a time, becomes more frequent, and at the same time softer, after the operation. One effect of blood-letting in inflammatory diseases is well ascertained, so far as understood, and practically very important, viz. that by causing, according to the common expression, relaxation of the extreme vessels, by lessening that morbid impetus of the blood by which, during the state of inflammatory fever, the natural excretions are apparently impeded, and at the same time, by promoting absorption into the blood, it favours the effect of all other evacuating remedies, intended to act on the excretions of individual parts of the system. Hence it was judiciously laid down by Hoffmann as a general truism regarding this remedy " Post vene- sectionem saepe excretiones salutares sanguinis, imo alvi, sudoris, urina? vacuationes, melius et liberius quam ante earn succedunt." In judging of the effects of blood-letting on inflammation, it is important to ob- serve, that the remedy may be highly beneficial, even in cases where the inflam- mation may extend, or the effusions consequent on it increase, after its use. It may often be observed, as in cases of pneumonia, that after full bleeding, the fever subsides, and the breathing is considerably relieved, but nevertheless the indica- tions by auscultation and percussion, of the extension of the effusion in the lungs and pleura continue for some days. But if the febrile symptoms do not return, and the breathing continues easy, it may nevertheless be confidently predicted that, under proper management, and in a sound constitution, the case will termi- nate favourably, and the effusions gradually disappear, by absorption and by expec- toration. In such cases it seems quite reasonable to infer that the intensity of the inflammation and the quantity, probably also the density, of the effused fluids, are restrained by the bleeding, and the latter kept within the limits which the natu- ral action of absorption can remove; and from what we may often observe of the pro- gress of erysipelas on the skin, in the more inflammatory cases of that disease, which are moderated and prevented from extending inwards to the cellular mem- brane, although not prevented from spreading along the surface, by blood-letting and analogous remedies, we may feel warranted in adopting this conclusion. But this consideration seems to have been in some measure neglected by Laennec and others in France, whose attention has been so much fixed on the physical indica- tions of effusion and disorganization of the lungs, and whose estimate of the value of blood-letting in inflammations within the chest is much lower than that which most practitioners in this country have been led, from their observation of such diseases, to adopt. It is in a few cases only that blood-letting can be said to cut short inflammation; the more usual effect to be hoped for, is more correctly ex- pressed by saying, that it disposes it to a favourable termination. While such benefits are to be derived from the prudent use of blood-letting in the strictly inflammatory diseases, and in their early stage, it'is equally certain that in diseases not strictly of that type, and in the abvanced stages even of the best marked inflammations, it may either aggravate and prolong the disease, or even rapidly and considerably determine its fatal event; and nothing, therefore, can be more important for the young practitioner than the diagnosis of the truly inflammatory diseases, of the very various intensity with which they attack dif- ferent persons, and of the degree of lesion of structure which may in any indivi- dual case have been already affected by them. The symptoms by which such distinctions are to be established belong, of course, to individual diseases, and cannot be advantageously stated here; but there are two symptoms common to all inflammatory complaints, and often guiding in a great 112 inflammation, ( Treatment.) degree the use of blood-letting, on which a few observations may be made; these are the state of the pulse, and the state of the blood, in inflammatory diseases. In inflammatory diseases, the pulse may very often be distinctly observed not only to be more frequent, but also to he fuller, i. e. to cover a larger surface of the finger, and give the sensation of a greater expansion on each systole of the heart —to he firmer or stronger, i. e. to be less compressible—and to be sharper, i. e. each of its pulsations to take place more suddenly* than in health; and when blood- letting takes a favourable effect in these diseases, or when they are spontaneously subsiding, it may be observed to become not only less frequent, but also smaller, more compressible, and softer. In general, it may be stated, that the more dis- tinctly all the deviations from the natural state of the pulse can be observed in inflammatory diseases, we have the more confidence in blood-letting as the appro- priate remedy; and that hardly any case of inflammatory disease demanding the remedy occurs, in which a deviation from the natural state in one or other of these particulars is not sufficiently obvious. But there are many cases of active inflam- mation admitting of the most essential benefit from blood-letting, in which one or more of the peculiarties here stated are absent. In one stage of inflammation within the cranium we have very often the slow but firm and sharp pulse, ob- served also in certain cases of inflammation within the abdomen; and in many cases of peritonitis and enteritis we have the frequent but small pulse, sometimes not distinctly harder or less compressible than in the natural state. It is also to be remembered that in youth the pulse is easily excited to a state differing from the natural in all the particulars above noticed, in the early part of febrile com- plaints which are not inflammatory; and again, that in old age, when the arteries have lost somewhat of their elastic power, and transmit impressions from the heart with less modification than in the natural state, particularly if the heart is at the same time affected with any degree of hypertrophy, the pulse is generally fuller, firmer, and stronger, or even sharper, than in the natural state. In regard to the buffy coat in the blood, there are occasional anomalies which are not yet understood; but the general fact is, that when inflammation is intense, there is not only a thick but a firm or contracted layer of coagulable lymph on the top of the crassamentum, implying that the particles of the fibrin have not only separated more completely from the colouring matter, but aggregated together more closely, or probably have continued longer under the influence of that vital property of attraction among themselves on which coagulation depends, than is usual. The formation of a thick but loose and flocculent buffy coat is often ob- served in complex cases, as in typhoid fever, combined with local inflammation; implying apparently that, although the separation of the fibrin from the colouring matter is complete, the vital property of attraction in its own particles is soon ex- tinguished, and this gives much less encouragement to the repetition of blood-let- ting. If, however, as it is most probable, the blood acquires this change of property, by passing through the vessels of the inflamed part, it is easy to understand that, for some time after even intense inflammation has set in, the buffy coat will be slight or even imperceptible; and again, that when inflammation of some standing is de- clining, or still more, when it has passed into the stage of suppuration or ulceration, the buffy coat will still be found in perfection; and, therefore, that its absence or slight degree in the early stage of inflammation is no reasonable objection to blood- letting ; and that its presence in the advanced stage (especially if suppuration is going on) is no indication for the remedy; which are accordingly approved practical observations. The quantity of blood which should be taken in a case of well-marked inflam- mation, seen in its early stage, should never be prescribed beforehand, the only * This last peculiarity Dr. Rush distinguished by the term quickness, as distinguished from frequency ; and it is really denoted by the artery springing quickly against the finger, and as quickly subsiding again; but the term sharpness is certainly that which in common language is most generally applied to it. inlfammation, (Treatment.) 113 sure rule being to continue the loss of blood until either the pulse is affected, or giddiness and faintness are felt, or the local symptoms are decidedly relieved. Dr. Culle'n's statement, that for an adult, previously in ordinary health, any thing below 12 oz. is to be regarded as a small bleeding, and any thing above 16 as a large one, may be held to be a fair average. From strong full-blooded men, distinctly affect- ed with inflammation, from 25 to 35 oz. may often be taken with signally good effect. A single bleeding, even although carried to syncope, is seldom sufficient to control a well-marked internal inflammation; and Sydenham's estimate of 45 oz. as the average quantity requisite to meet the danger of a decided pleurisy, is not ex- cessive. Dr. Clark's statement as to young children, that 3 oz. are a full beeding from a child of one year, but that 2£ or 2 may be taken at that age within a day or two, and even repeated in obstinate cases, may likewise be quoted as a judicious one. Three leeches bleeding well, are a full bleeding for a child of one year, at least of the average strength of those brought up in great towns; and if one is added for each year of the child's age up to five; a fair number for a single evacuation may be obtained. Beyond this age, in strictly inflammatory cases, bleeding at the arm is certainly to be preferred. There are a certain number of cases in which the symptoms of inflammation in its early stage, both local and general, either continue more obstinately, or occur more frequently, than usual, and in these it is of much importance to be aware how far the remedy may sometimes be carried with good effect. There are various cases on record of pneumonia beginning with unusual intensity, in which 70 or 80 oz. within 12 hours, or 100 within 24, have been taken with success, and in some of these farther blood-letting was necessary before the disease finally subsided. The late Dr. Gregory used to quote the case of a medical man in Edinburgh (at this moment in perfect health) who was bled to the extent of 127 oz. in 27 hours, (102 of these within 5 hours,) by his own direction, in incipient pneumonia, which was thus completely subdued. Of the repeated occurrence of the disease, the most re- markable example that occurred in the practice of the same eminent teacher, who is well known to have had much experience in such cases, and to have watched the effects of the remedy with great accuracy, was one of repeated attacks of pneumonia, confining a patient to his room for three months, in the course of which he lost precisely 392 oz. of blood from his arm, and from which, in the end, he re- covered perfectly. Mr. Cline had a case of concussion of the brain in St. Thomas's Hospital, in which 320 oz. were taken within three weeks, with success. It is hardly necessary to say that such cases are not quoted as models for gene- ral imitation; a great majority of patients, in the most decidedly inflammatory diseases, would certainly sink under a much less active treatment, or pass into a state obviously forbidding the use of the lancet; but when we meet with cases where the early symptoms of inflammation resist obstinately, or recur frequently, it is of the utmost importance to know how far the ordinary remedies may be carried, under prudent management, with success; and it may be confidently stated that no cases afford a more pleasing retrospect than those in which cautious perse- verance in the use of this " summum remedium in maximis morbis," has been ultimately rewarded with complete success. The question of the comparative usefulness of general and local blood-letting in internal inflammations is not easily decided, but fortunately, in each individual case of severity, it is quite possible to try both and be guided by the effect observed. No doubt can be entertained as to the importance of local bleedings succeeding venesection, in all inflammatory diseases where the symptoms do not speedily yield to the lancet; but in a case of decided idiopathic internal inflamma- tion, attended with general fever, it may be confidently stated that early, and if the symptoms continue, repeated bleeding at the arm should certainly never be omitted, excepting only in the case of inflammation of the heart supervening on rheumatism; in which case repeated local bleedings, chiefly by cupping, are attended with more satisfactory results than bleeding at the arm. And in the case of the pericarditis in particular, it is easy to understand that full general bleeding will be Vol. I.—15 114 inflammation, ( Treatment.) attended with a danger quite peculiar, from the pressure of the effused fluid on the surface of the heart being naturally most injurious when the blood distending its cavaties is subjected to sudden and great diminution of quantity. The dangers to be apprehended from excessive or injudicious blood-letting, espe- cially from the frequent repetition of the remedy, form a subject of great practical importance, of which a general outline only can here be given. The danger of immediate death from the haemorrhage, in the hands of an atten- tive practitioner, may be regarded as trifling, there being always some warning, from the first symptoms of syncope, with or without spasms, of the time when it is prudent to stop a single blood-letting: and generally such indications of general debility and of enfeebled circulation, from the compressibility of the pulse, coolness of the skin, deficiency of mucous secretions, particularly dryness of the tongue, &c, as sufficiently inform us when the repetition of the remedy has become a mat- ter of doubt and delicacy at least, if not absolutely inadmissible. But it must be allowed that there are many cases in which the system is powerfully affected by loss of blood, in which the repetition of the remedy is dangerous, if not immediatey, at least in its ultimate result in the disease; and in which, nevertheless, there is a fallacious degree of fulness and even strength of the pulse, and a combination of symptoms which, to those unaccustomed to observe them, might seem to denote determination to the head, perhaps inflammation of the brain, and to demand farther loss of blood. Of the possibility of this fallacious fulness and even sharpness of the pulse, (gen- erally a somewhat tremulous and easily compressed, but nevertheless sharp pulse, according to the notion formerly explained as being annexed to this last term,) some of the experiments of Dr. Parry on animals killed by repeated bleedings, and in which the pulse was " full and bounding" almost to the moment of death, afford unequivocal proof. And it were easy to quote practical observations by Rush, Armstrong, Marshall Hall, Travers and others, illustrating this " re-action after the loss of blood;" which may, perhaps, be most correctly described as a modification of inflammatory fever, ^produced in a great measure by the loss of blood, and persisting after the local inflammation has subsided or passed into a state no longer demanding evacuation. This peculiar febrile state is marked by the frequent, full, vibrating or sharp, but easdy compressed pulse, with heat of skin, generally, however, not persistent if the bed-clothes are removed from the part felt—generally with sense of palpitation and of throbbing in the head, and tinnitus aurium; sometimes impatience of light and sound; the symp:oms aggra- vated, and vertigo produced by the erect posture; the face and lips pale, and all muscular motion difficult and generally tremulous. This state occurs chiefly in females of irritable constitution; and is best relieved by alternation of laxatives and opiates, often with the cautious use of wine, ammonia, or other stimuli. Where it co-exists, as occasionally happens, with pretty urgent symptoms of local inflammation, it presents a case of much difficulty, but in which, although blood may often still be taken locally, general blood-letting is certainly inadmis- sible. J The idea of subsequent injury to the constitution from the use of blood-letting, in inflammatory diseases, and particularly the idea of dropsy beino- thus produced, may in general be regarded as quite visionary. In persons liable to nervous affections, particularly to the various forms of hysteria, it is certainly true that an aggravation of that tendency is to be expected; which, however, will in gen- eral be only temporary, if the inflammation has been effectually subdued. One ot the chief practical evils which is always to be apprehended from large and repeated blood-letting is, that it always increases the facility with which the sur- face of the body may be chilled, and therefore the liability to relapse, or to the excitement of fresh inflammatory disease, perhaps of worse character, or any subsequent exposure to cold. J But the principal cautions which it is necessary to keep in mind, as to the use ot blood-letting in inflammatory diseases, have reference, not simply to the subsequent effects of the evacuation on the system, but to the alteration to be inflammation, (Treatment.) 115 expected from it on the progress of the existing disease; and in this view we must always carefully attend—I. to the period of the disease at which we are to use the remedy; 2. to the kind of the inflammation; and 3. to the complication which may exist of inflammation with other diseases. 1. When we say that the period of the disease, even in cases of healthy in- flammation, often decidedly contra-indicates, and still oftener makes us doubtful as to the result of blood-letting, we do not mean merely the number of days from the first decided attack of the disease (although that always demands attention;) but we must attend particularly to the proofs of effusion or disorganization con- sequent on the inflammation, having already made such progress as to indicate that the alteration of structure already effected, rather than the alteration of action which leads to it, demands our chief attention. And in general, as already remarked, this may be apprehended when we see a manifest change in the con- stitutional or febrile symptoms, attended with continuance or increase of the local symptoms. When the pulse has become slow or irregular, at the same time that the pain of head has passed into delirium or coma, in phrenitis or hydro- cephalus; when it has become soft and compressible, or very frequent, or when the fever has taken the form of hectic, in inflammations within the chest, while the cough, or the dyspnoea has continued and increased; when rigors have supervened on hepatitis; when a soft and compressible, or very fre- quent pulse, and cold sweats, have taken place in enteritis, without relief of the bowels or abatement of the tenderness of the abdomen, thoracic respiration, and vomiting; we may always suppose that effusions have taken place to a consider- able extent, and that if the inflammation exciting them has not subsided, at least the febrile re-action, by which that inflammation had been supported, and on which blood-letting could exert its chief powers, has so far abated, that the time for active depletion is nearly over. If recovery is possible after this period, a long and slow process must be gone through before it can be perfected; and this will require a certain strength of vital action, and may be frustrated by any means which farther depress the vital powers; nay, it may, in many instances, be obviously promoted by means which excite the system generally, and stimu- late and strengthen the circulation. In many such cases, more definite information is attainable, particularly in the case of inflammation within the chest, whether affecting the bronchia?, the sub- stance of the lungs, the pleura, the pericardium, or inner membrane of the heart —the indication given by examination of the chest and of the sputa, and by auscultation and percussion, prove the extent of effusion, and the degree in which the play of the lungs or heart is impeded by it; and these, taken along with the state of the pulse, heat of skin, and general strength, may often enable us to speak with much confidence as to the question—always presenting itself in the ad- vanced stage of these diseases—whether there is more danger from weakening the circulation by blood-letting, when such impediments to the action of parts within the chest already exist, and can only be remedied by a slow natural pro- cess of absorption, or from allowing such inflammation as still exists to go on, unchecked by farther loss of blood. 2. That inflammation may exist, of a nature not to be subdued, even to be aggravated, by blood-letting or other evacuations, is quite certain from such ex- periments as those of Magendie as to the eye, and of Gendrin as to the stomach; in which the kind of inflammation of mucous membrane formerly mentioned was brought on by inanition, and could only be relieved by fuller nourishment, re- storing the strength of the circulation, and probably restoring to the mucous membrane its natural protecting mucus; and that the kind of inflammation which is recognised in a patient affords very often a reasonable ground of objection to full blood-letting, is sufficiently obvious when we attend to the known history of scrofulous, rheumatic, and gouty inflammation. In the first of these, it is true, that on occasion of a recent inflammatory attack, when the symptoms approach most nearly to those of healthy inflammation, we have every reason to believe that blood-letting is often of the most essential importance, preventing aggrava- 116 inflammation, (Treatment.) tion of disease already existing, or arresting disease which would otherwise be established. But it is equally true that scrofulous inflammation is less under the influence of blood-letting than healthy inflammation; and farther, that scrofulous diseases occur chiefly in weakly persons, in those whose mode of life in early youth has been debilitating, and in those recently weakened by any considerable evacuations. Therefore, by full and repeated blood-letting in scrofulous cases, while we make little impression on the inflammation that exists, we incur a great risk of so far lowering the constitution as to make it more liable than pre- viously to fresh attacks of inflammation, or to other scrofulous diseases perhapa not inflammatory in their origin. Again, the recorded experience of all ages informs us (whatever we may con- jecture as to the explanation of the fact) that the inflammation both of rheumatism and of gout is very liable to metastasis, and that, although it may often be mode- rated (particularly that of acute rheumatism in a healthy constitution) with very good effect by evacuations, yet it is by no means desirable that it should sud- denly recede from the extremities; because if it does, inflammation in a more vital organ, or in the case of gout, a kind of internal neuralgia, even more imme- diately dangerous, is very likely to follow. In the case of erysipelas, to a certain degree, and in that of all the specific in- flammations of the skin already noticed, in a much greater degree, the nature of the inflammation may also be urged as a reason against full blood-letting, and in favour of the stricdy " expectant practice;" but these are cases either of inflam- mation without fever, or of inflammation complicated with another and generally more formidable disease, falling therefore under the next head. 3. The complications of inflammation which often contra-indicate blood-letting, and always impose the necessity of caution in regard to it, are in a general view of two kinds; that with other febrile and particularly contagious diseases, and that with chronic and particularly organic diseases. In regard to the complication of inflammation with idiopathic fever or with the contagious exanthemata (in which we include erysipelas,) the general principle is, that such inflammation, whether of the kind that is essential to, and charac- teristic of, the disease, or of that which is only an accidental concomitant, is never the sole, and seldom the chief, cause of danger. The body is under the influence of a poison, generally absorbed from without, which gives a peculiar character to the inflammation, and likewise excites a peculiar form of fever, often very dangerous when the inflammation, external or internal, is trifling. In the course of the disease, the poison, after being enormously multiplied, by some mysterious process, is expelled from the body. Whether the inflammation is part of the process by which this expulsion is effected, is indeed doubtful, but it is certain, that in most of these diseases, the inflammation, at least that which is characteristic and peculiar to the disease, cannot be prevented from running a cer- tain course without imminent danger to life. The danger in the course of these diseases depends often mainly on the de- pressing effect of the morbific poison, gradually influencing the system at large, and especially the fundamental function of circulation, and producing typhoid fever; but it often depends on the combination of the depressing influence with inflammation, internal or external; and sometimes it depends so much on the in- tensity of the inflammation and so little on any general depression of the powers of life, that the disease demands and bears evacuations nearly as in idiopathic inflammation. In judging of the degree in which the danger of individual cases depends on the one or the other cause, there is of course much room for the exer- cise of judgment and discretion. One general observation may be made, which is of great practical importance, that in all such complex cases, where contra-indica- tions exist, if blood-letting is to be practised (and in the accidentally concurrent inflammations in many cases of such diseases it is highly beneficial,) it should be practised as early as possible, in order that it may be as small as possible; all experience informing us that a very moderate loss of blood in the early stage of inflammation, (Treatment.) 117 inflammation will often produce much more effect on the extension and course of the disease than a much larger quantity at an advanced period. There is another element which must always be taken into consideration here, which is quite peculiar to such diseases, viz. the nature of the prevailing epi- demic; for it is the general result of the observation of medical men in different ages, that in different epidemics, the type of the same disease so far varies, that the local inflammations may be more frequent and dangerous in the generality of cases occurring in one, and the general typhoid state in those occurring in another. Thus it is the general result of the experience of the present writer and he believes, of most practitioners who have seen much of the epidemic fevers prevalent in Scot- land from 1816 till 1820, and again of those prevalent since 1826—that blood- letting was both more demanded from the firmness of the pulse and the urgency of the local symptoms, and better borne at the former time; and that the danger much less frequently depended on mere depression of the circulation; and again, that, in the latter epedemics, this last part of the symptoms has been much more generally urgent, the use of stimulants has often appeared much more important and beneficial; and that full blood-letting, even early in the disease, has often ap- peared to exert a very injurious influence over its subsequent progress. Similar observations have been made on different epidemic visitations of all the febrile and contagious diseases. Of the caution in regard to blood-letting which is imposed by the presence of chronic, and especially of organic disease, we may merely enumerate the cases of inflammation of the lungs or bronchia? combined with disease of the heart, or with previous long-continued asthmas and its usual attendant, emphysema of the lungs; and again, of inflammation within the abdomen, whether of the serous or mucous membrane there, combined with organic disease of the liver. Such cases are very common and are very often farther complicated with dropsical effusion partial or general. It is very important to be aware, and has been ascer- tained of late years more distinctly than formerly, that none of these complica- tions ought to prohibit blood-letting when the inflammatory symptoms are re- cent, and the circulation tolerably firm and vigorous. But it is obvious, that, in such cases, the system is permanently under the influence of a cause which pre- vents it from recovering its natural strength after any great evacuation, as it otherwise would do. And in several such cases, a more special cause of danger from much loss of blood may be pointed out, particularly in the cases of advanced bronchitis and emphysematous lungs, in which free expectoration is both difficult and necessary for recovery; and the cases of dropsical effusion where a mechani- cal impediment exists either to free circulation or to the expansion of the lungs. It is obvious, from these considerations, that the time during which blood-letting can be beneficially employed in such diseases must be very circumscribed; al- though it must be admitted, on the other hand, that some cases of all of these occur, in which the strength of the circulation is such as to make it safe and beneficial at a much more advanced period than in others. The case of mechanical ob- struction to the flow through the heart, from disease of its valves or of the aorta, unconnected with organic alteration either of the lungs or liver, is that in which the repeated loss of blood may generally be best borne. Much has been said, in some systematic works of age, sex, temperament, habit of body, habits of life, climate, and season, as influencing the use of this remedy; but the fact is, that there is no age, no sex, temperament, or habit of body; no description of human beings, and no climate or season, in which blood- letting may not, on certain occasions, be performed with advantage—nay there is none in which its neglect may not be fatal. All that can be said on those heads is chiefly important as pointing out the circumstances in which the indi- cations or contra-indications already stated are chiefly to be expected, but can hardly be said to establish new rules. In early life there is certainly ground for caution—first, because much febrile action may be excited even by slight inflammation, and secondly, because young 118 inflammation, (Treatment.) children are easily depressed by repeated evacuations, perhaps especially of blood; and are apt to fall when so affected into the state described by Dr. Gooch, Dr. M. Hall, and others, under the name of hydrencephaloid disease: in which stupor, with coldness and feeble pulse and vomiting, are the chief symptoms and in which stimulants are often signally useful. In very advanced life there is ground for caution, partly on account of the com- plication with alteration of structure, which may very often be suspected, even when it is not certainly known, and partly because the powers by which the capillary circulation is maintained, and the vital affinities by which the blood is applied to its various useful purposes in the economy, lose much of their efficacy at this time, and the system, therefore, has usually not the same powers as pre- viously of recovering from any debilitating cause. In regard to sex, it is important to observe that in women, slight inflammatory attacks, with severe pain, and often with much fever, or severe neuralgic attacks, with threatening of inflammation in the spinal cord, in the sides of the chest, and in the viscera of the abdomen and pelvis, often occur, and mislead young practi- tioners into the belief that violent internal inflammation exists when it does not. But it is not less true that the most intense inflammations occur in them proba- bly more frequently than in men; and it were a fatal error to suppose that the presence of nervous or hysterical symptoms implies the absence of serious in- flammation. In regard to climate, the most truly important observation seems to be, that in hot climates the progress of febrile and inflammatory diseases—at least on Euro- peans—is accelerated, and the time when blood-letting can be useful of course proportionally circumscribed. The sanguine temperament is that in which the greatest intensity both of pain and of fever may be expected to attend a given amount of inflammation; and therefore when we have urgent general symptoms attending local inflammation in persons of a temperament much removed from the sanguine (in the phlegmatic or melancholic,) we have the more reason to suppose that the inflammation is intense; and, if it be in the early stage, that full blood-letting is demanded. But it is of much more importance to observe the degree of strength of habit, than the temperament in judging of the extent to which blood-letting may be carried. The inhabitants of large towns, partly on account of their more sedentary life, partly of the impure air which they habitually breathe, partly of their less regular mode of life, their more frequent mental anxieties and irritation, are of feebler habits; and all the cautions as to repeated loss of blood apply to them more than to country people. There are indeed many of them, in comfortable circumstances and of regular habits, who bear bleeding per- fectly well; but there is a class well described by Dr. Armstrong, always nu- merous in large towns, whose subsistence is precarious, their habits irregular, and often dissipated, who are exceedingly prone to inflammations, but have it in a form modified by these circumstances, and especially by the habitual use of strong liquors. In many of these full blood-letting will produce fits of delirium tremens; in others it affects variously the nervous system; and in all it must be expected to depress the circulation more permanendy than in better constitutions. In all such cases, our main resource is the early detection of inflammatory dis- ease, and the early, and because early, moderate, and yet effectual, use of blood- letting. Having said so much of this our summum remedium in inflammatory diseases, we may comprise in a few words all that need be stated in general terms as to the other classes of remedies to be employed in such cases. 1. When inflammation is once near the surface of the body, we have a power- ful means of repressing it in the application of cold, which, by causing constric- . tion of the dilating vessels, prevents those congestions and stagnations of blood which seem to be essential to the inflammatory effusions. The application of cold water to a burn, which has caused inflammation, and commencing vesication— pr to a bruise or sprain, affords unequivocal evidence of the power of this inflammation, (Treatment.) 119 agent, but, in order that it may be effectual, it must be applied either uni- formly or very frequently and assiduously for many hours together; otherwise the inflammation will start again, as if with renewed vigour, on each cessation of the application, as long as the general strength of the circulation continues, and the remedy will, on the whole, rather retard than hasten its decline; and it is difficult to do this without some risk of the injurious effects of cold. In those varieties of in- flammation which have the natural tendency to shift their place, and especially to affect internal parts, it need hardly be said that this mode of repressing external in- flammation is inadmissible. Although cold applications may be used in these, when the circulation is firm and vigorous, it must be only with the intention of relieving the feelings of the patient—not to such an extent as to affect materi- ally the progress of the inflammation. Of internal inflammations, that within the head is that in which the assiduous application of external cold has been most esteemed, both in the way of frequent sponging or aspersion, and in that of occasional stronger effusions; but, perhaps it is rather in cases or sub-acute inflammation, or determination approaching to the inflammatory state (as in the course of idiopathic fever,) that it is most use- ful. Certainly, in cases of idiopathic inflammation, or of threatening hydroce- phalus, it cannot be urged as superseding the active depleting measures. In some cases of peritoneal inflammation, the assiduous external application of cold is grateful to the patient, and probably may assist in restoring the natural state of the bowels: but the application must be strictly confined to the inflamed parts, and this is often difficult. This observation applies still more to the application of cold, practised occasionally on the Continent, we believe hardly at all in this country, in cases of cynanche, especially of croup. 2. Of the various sedative medicines which, at different times, have been highly recommended as capable of controlling both the local and the general disorder in inflammatory diseases, we may assert in general, that no one is generally thought in this country deserving of confidence which is not nauseating; and that the antiphlogistic effect, if not absolutely dependent on, seems very much connected with, the nauseating sensations, and accompanying depression of the heart's action. The effect of digitalis in lowering the pulse is seldom to be ob- tained without its nauseating effect; and this can hardly be produced within so short a time as the progress of an acute disease demands, without danger of fatal syncope. Whatever may be the specific power of colchicum over gouty inflam- mation, it is certainly not to be depended on as sensibly influencing simple, or even rheumatic inflammation, unless so used as to nauseate. Several high authorities on the Continent have expressed a confident opinion of the antiphlo- gistic virtue of tartrate of antimony, when given in large quantity, after tolerance of the medicine has been established, and when it produces no sensible effect; but such trials as have been made in this country have not, so far as is known to the present writer, established this principle to the satisfaction of the profession* Indeed, according to his experience, the effect of from a quarter of a grain to half a grain of tartar emetic every two hours during the time of waking, in cases even of well-marked internal inflammation, is distinctly nauseating, when blood has been previously freely drawn; and as the chief benefical effects of the remedy, as auxili- ary to blood-letting, have been observed in connexion with occasional fits of nausea, there has been no great anxiety to observe the effects of pushing the medicine farther. The antimonial solution thus used, or other nauseating medi- cines, is probably the most powerful auxiliary to blood-letting in the early stages of inflammations within the chest, especially in that of the substance of the lungs; and it is a very powerful remedy, also, in those cases of affection of the brain. occurring in fever, in which there is high delirium and an approach to inflamma- tion, though without nausea; but in the early stage of almost all cases of idiopathic inflammation in the head, as well as in those of the abdomen, there is so much nausea and vomiting as obviously to contra-indicate the remedy; and, in all cases, caution is requisite in its use, on account of its sometimes violent effects on the heart's action, and on the stomach and intestines. 120 inflammation, (Treatment.) 3. the most frequently employed of all the auxiliaries to blood-letting are the various methods of derivation, of which purging is by far the most generally im- portant. This is the main auxiliary to which we must trust in cases of inflamma* tion within the head; and its use there is the more important that (as Dr. Abercrombie has stated) purgatives may be used fully, and sometimes most effi- ciently, after the symptoms of effusion consequent on inflammation in the brain, have come on, and when farther loss of blood is useless or even injurious. In in- flammation within the chest, although occasional laxatives are proper in the view of lessening the general febrile state, they are of less essential importance; and when there is much expectoration in the latter stages, it is generally, and probably justly, thought that much purging may be injurious. In inflammation of the intestines, both of the serous and mucous membranes, they were certainly much too generally employed in this country within these few years; but it is now more generally understood that, in reducing inflammation there, they are not only of little efficacy, but always of doubtful, and sometimes of injurious, effect—that procuring a regular action of the bowels is a secondary object, not to be directly urged until the inflammation has subsided; and that even for attaining this object, the mildest laxatives and enemata, generally alternated with opiates, are the most appropriate means. Vomiting appears to be an important auxiliary to blood-letting chiefly in cases of inflammation of the larynx, trachea, and bronchia?, especially in children, where it seems to have a special effect, partly as an expectorant, and partly as an anti- spasmodic. The effect of diaphoretics and sudorifics in inflammatory complaints is not easily referred to any fixed principle. In many of them, especially in thoracic inflamma- tion, there is often, full sweating without the least alleviation; and it is certainly highly inexpedient, in the height of any inflammatory disease, to urge the use of such sudorifics as produce a manifest previous excitiment of the circulation. In the inflammatory diseases of children, in particular, the premature use of the warm bath is certainly often injurious. Yet there are cases of strictly inflammatory dis- eases, in their early stages, particularly of bronchitis, of dysentery, and of rheuma- tism, in which sweating, generally succeeding to moderate loss of blood, sustained sometimes for two or three days, and with proper precautions against subsequent exposure to cold, is signally beneficial; and they are perhaps more generally use- ful when the violence of internal inflammation has subsided. The use of blisters and other counter-irritants is confined chiefly to peculiar cir- cumstances of inflammatory complaints—to the later stages of acute inflammation, when the excitement of the system has been so far reduced by blood-letting; to the cases of more chronic or sub-acute inflammation; e. g. to many cases of bronchitis and rheumatism ; and again to the inflammation, and especially the slow scrofulous inflammation, of those textures where the whole progress of inflammation is slow: bones, cartilages, and ligaments. In many of these last cases, the issue or seton is the most suitable and effectual form of counter-irritation. In all forms, the de- gree of excitement they occasion is a serious objection, particularly in children, in whom also, the ulceration and sloughing, consequent on blisters, if applied only for a few hours, in a feeble habit or in a depressing disease, is often not only trouble- some but dangerous. 4. Many practitioners in this country, since the time of Dr. Hamilton, of Lynn Regis, have been firmly convinced that there is a peculiar or specific virtue in mercury, affecting the mouth, and especially in the conbination of calomel and opium, in arresting inflammation, and controlling the deposition of lymph from it; and that a power of this kind is exerted over the inflammation of the iris, and the effusion of lymph upon it, in many cases of that disease, no one can doubt But that a similar power, is exerted, in a degree adequate to the object required, in any inflammation of internal parts, is much more doubtful. That calomel and opium is a useful medicine in many internal inflammations is granted by all, be- in flammation, (Treatment.) 121 cause the soothing effects of the opium are often desirable, and the calomel is one of the simplest and most effectual means by which some of the injurious effects of opium may be corrected: but the main question, as regards any specific virtue of mercury, is this—Do the symptoms of inflammatory diseases subside more ra- pidly, and more certainly, when the murcury has affected the mouth than with- out that occurrence ? and on this point the present writer cannot hesitate, after con- siderable experience, to reiterate an opinion he formerly expressed, that he has more frequently seen them aggravated, or transferred to another part, on that event taking place, than relieved ; and that the cases in which that combination has always seemed to him most useful have been those in which, the symptoms having subsided, it was withdrawn without the mouth being touched. 5. That opium is an important and valuable auxiliary to blood-letting in abdo- minal inflammations, is a principle which we consider to be firmly established by the practice of various physicians is this country, and perhaps not duly appreciated in others. It appears to us that its value (except as a mere palliative to uneasy feelings) is nearly confined to the inflammations of the intestines, enteritis, and dysentery, and that it is important in them not to diminish the quantity of blood which should be drawn to subdue the inflammation, but to relieve those very op- pressive sensations which seem to be the connecting link between the inflammation in the intestines and the actions of the heart, and by which these actions are so often rapidly and irretrievably depressed. Under the full use of opium, after bleeding in these diseases, these feelings are often relieved, vomiting allayed, sleep procured, (whether with or without sweating does not appear to be mate- rial,) and the pulse is found to rise in strength; and if, as very generally hap- pens, in well-marked cases, the inflammatory symptoms recur, blood-letting may be repeated again and again, without symptoms of sinking. The disease is placed as to its possible duration, and the effects of repeated blood-letting, more on a foot- ing with inflammations of other parts, than it is when this auxiliary is omitted. Under this treatment, we can say with confidence, that the success of treatment in these inflammations, when attended by the peculiar depression of the circula- tion, and when the mflammation is of the healthy character, as distinguished from the erythematic and often epidemic peritonitis, is very considerably greater than when opium is withheld. 6. There is yet another class of remedies of great and certain efficacy in cer- tain circumstances of inflammatory diseases, although of course requiring much discrimination in their use, viz. the stimulants. These are admissible, of course, only in the later stages, but sometimes sooner than the indications for local blood- letting, or the time of its useful employment, have ceased. They may be demand- ed by two distinct considerations: 1. By there being such indications of debility or definite action in the pulse, skin, tongue, and voluntary muscles, as are in them- selves very dangerons, and may render a local disease fatal, which might other- wise either have abated or passed into a chronic and comparatively inert state. 2. By certain consequences having already resulted from the inflammation, known to be irremediable for the time, but admitting of a subsequent slow process of cure by the provisions of nature, provided a certain amount of the vis vita? in the system in general can be maintained for the requisite time. Dr. Abercrombie has shown that the deadly paleness and coldness, with cessa- tion of the pain, and sinking of the pulse, so often seen and so generally fatal in- the last stage of enteritis, may in a few cases go off under the cautious but conti- nued use of stimuli. There is no case in which more decided beneficial effects can be observed in some instances from stimuli, than the advanced stage of bron- chitis, when the breathing is very short and hurried, the mucous and sub-crepitous rale general on both sides of the chest, the skin cool, and the pulse sinking. In some such cases, the breathing is relieved by full expectoration, obviously promoted by the stimuli; but in others it gradually improves as the pulse rises in strength, al- though the expectoration is scanty. It has happened to the present writer repeat- edly to meet with cases of the true peripneumony, (no doubt partial,) marked by Vol. I.—16 122 inflammation, (Treatment.) the peculiar sputa, with the absence of respiration in the affected part of the chest —neglected until their advanced stage—attended with a similar depressed state of the circulation, and recovering (of course with some permanent injury to the lungs) under the use of stimulents exclusively, taken in such quantity, and followed by so rapid abatement of the most distressing symptoms, that they could not be supposed to have exerted no influence on the disease. Again, although there be no such immediately alarming symptoms, if bronchitis has produced general effusion into the bronchia? (as in many advanced cases of asthma and of hooping-cough;) if a portion of lung has been consolidated; if an extensive and probably partly puriform effusion from decided inflammation has taken place in the cavity of one side of the chest or abdomen; if an abscess has formed in the liver; if a portion of the mucous membrane of the intestines has been thickened by ef- fused lymph, and then passed into ulceration; if a bone has become carious, a cartilage has ulcerated, or even a capsular ligament of a joint been much thick- ened by inflammatory deposites; if the cornea has been affected, first with pustules and then with ulcers, from the strumous form of ophthalmia—whatever influence local remedies may or may not have in such lesions, it is certain that a long pro- cess of absorption, of ulceration, of healing by granulations, &c. in these different cases, must be gone through; and that a certain degree of strength of habit is necessary, that these processes may go on favourably. We know, from experi- ments on animals, that inflammation, with all such consequences, (e. g. in the eye,) may be produced, if not merely by inanition, at least by causes acting on a very exhausted system, and producing this effect by reason of the exhaustion; and that all may be removed merely by giving sufficient nourishment; and, therefore, we can easily understand, what experience abundantly demonstrates, that not only the antiphlogistic remedies after a time must be discontinued, but the antiphlogistic regimen relaxed, even sometunes at the risk of temporary aggravation of part of the disease, in such cases; and that the best effects should result from the gradual introduction of a tonic regimen, from country air, exercise, moderate mental ex- citement, and a gradually improved diet. Such cases illustrate nothing so strongly as the mischief which may be done by practising for the names of diseases; and forcibly remind us of the judicious aphorism of BoerhJave, " Nullum remedium in morbis cognovi, quin solo tempeslivo usu tale fiat." C 12a ) FEVERS. GENERAL DOCTRINES OF FEVER. Definition.—Forms of fever.—Local diseases in fever.—Theories respecting the nature of continued fever.—Exanthematous or eruptive fevers.—Classification of fevers. Fever (febris, from fervere, to glow, to be hot) is so named from one of its most prominent symptoms—a sense of increased heat. The term has a double signification, both in nosographical and in familiar pro- fessional language. For sometimes it is applied, especially in the pleural num- ber, to all febrile diseases, including primary fevers, eruptive fevers, and acute local inflammations. And at other times it is used, particularly as a singular noun to denote primary fevers only, or fevers proper; while, for embracing the whole class of febrile diseases, the more generic term Pyrexiae is commonly em- ployed; which however, according to its original meaning (from irvpitrra, febri- cito, derived from ■*»}, ignis,) does not essentially differ from the more specific term, fever. It is in the restricted signification, implying those febrile diseases where the pyrexia is simple, or not combined, at least necessarily, either with eruptions of the skin, or with local inflammation, that the subject of fever will be here in the first place considered. Fever has been variously defined. Probably no better definition can be found than the following, a modification of that sanctioned by Cullen:—After a pre- liminary stage of langour, weakness, and defective appetite—acceleration of the pulse, increased heat, great debility of the limbs, and disturbance of most of the functions without primary local disease. It is a singular instance, however, of the extreme difficulty of arriving at correct nosographical definitions, that scarcely any one of the characters here assigned is absolutely invariable; nor is it likely that any other definition will be found, which is not subject to the same defect. Forms of Fever.—Fever presents itself in a very great variety of forms. The most precise mode, perhaps, of regarding them in connexion with one another, is to proceed at the outset from the simplest of them, ephemera, or one day's fever. Ephemera, so called because it seldom lasts above twenty-four hours, begins with chilliness or rigor, paleness, weariness, a frequent small pulse, and indifference to food. These symptoms are followed in half an hour, or a little more, by heat of skin, flushed face, frequent hard pulse, occasionally headach, and a peculiar sense of fatigue, restlessness and slight soreness in the muscles, to which the name of febrile sensation, or febrile anxiety, has been conveniently given. When this state has continued for twelve, eighteen, or at most twenty- four hours, gentle perspiration breaks out; under which, in the course of little more than another hour, every essential symptom vanishes, leaving behind some exhaustion, muscular debility, and feebleness of the appetite. This disease, the simplest and slightest of all forms of fever, although on account of its shortness it seldom attracts much notice, is nevertheless not uncommon during the irregu- lar weather of our spring months in Britain. If such an affection be supposed to recur several times every other day, with an interval of comparative health in the intervening days, a clear idea will be 124 GENERAL doctrines of fever. formed of intermittent (ever in its most frequent and characteristic shape—the tertian type; and from the tertian may be derived all the other forms of intermittent. If, in the next place, the febrile state be conceived to be reinforced twice a-day, or oftener, by a fresh attack of rigor or chilliness, with subsequent re-action, be- fore the pre-existing pyrexia has materially subsided, a distinct conception may be formed of remittent (ever. From remittent fever most nosologists deduce the only remaining primary type, continued (ever, by supposing the remissions to become gradually less and less distinct; and this view may seem so far conform- able with nature, that almost all continued fevers present, more or less, a ten- dency to regular or irregular remissions, especially for some days at the com- mencement. But it is perhaps fully a clearer, and certainly a more direct way of deducing them, to conceive the ephemera merely prolonged to such a duration, as that its several stages occupy between four and nine or eleven days, thereby constituting, in the first instance, the simplest of all forms of continued fever, usually known by the specific name of inflammatory fever, or synocha. It is probable that inflammatory fever is the fundamental type of all primary continued fevers. It is acknowledged that all primary fevers, but especially those of the continued type, even in its simplest form of inflammatory fever, present, in comparison with other febrile diseases, a great degree of debility or exhaustion of the nervous system; which is marked among other symptoms by great mus- cular feebleness, both during the prevalence of febrile action, and for some time also during convalescence. Now sometimes, where inflammatory fevers are dis- posed to run a longer course than usual, the symptoms of nervous depression, ag- gravated undoubtedly by the pre-existing reaction of the circulating system, come to constitute in the latter stage the most conspicuous character of the disease: and in particular they veil more or less, and even sometimes overwhelm, the original character of pure reaction that distinguished the earlier stage, thus giving rise to extreme muscular depression, and disturbance of the powers of the mind in the shape of stupor with or without delirium. Such a sequence of pathological phe- nomena, conveys the clearest idea of the second well-marked variety of continued fever in its simplest form, which is commonly known to nosographists by the name of synochus. At other times again, the symptoms of exhaustion and dis- turbance, becoming still more prominent, show themselves at an earlier period along with the signs of reaction of the circulation, that is, before the close or even near the beginning of the first week; and thus they constitute the most striking general character of the disease throughout, and in some cases even become ex- cessive from the very beginning. Fever, in this shape, forms the typhus of nosographists—a term, which of late has passed into unprofessional language, and thereby acquired a vague meaning, almost equivalent to the generic word, fever. The three types of continued fever, synocha, synochus and typhus, are the spe- cies which were admitted by Cullen into his nosological system. Since his time, some have called in question the existence of the first type; others have multiplied the species. Many have doubted, and not a few have boldly denied, that such a thing as a primary fever, properly so called, is to be found in nature. But all that has been attempted in this particular corner of the theory of fevers since Dr. Cullen wrote, has had scarce any other tendency than to embarrass and obscure the sub- ject. Much has been done for the pathology of the various forms of fever by the researches of pathological anatomists; and the knowledge now possessed of its secondary affections has in consequence acquired an extent and precision, which in his days were unknown and indeed unattainable. But the views entertained of fevers in the abstract have not been rendered clearer; and many dogmas have been maintained, and still receive currency, which, in so far as they do not seem true to nature, cannot be supposed likely cither to advance medical theory, or to benefit medica] practice. All forms of continued fever, excluding always from that term eruptive fevers and acute local inflammations, may be arranged under three types, here specified. All forms which have been distinguished from them by medical writers in recent FORMS of fever. 125 times may be viewed, both philosophically and practically, as nothing else than varieties, presenting peculiar features imparted by incidental concomitants, yet not the less essentially belonging either to one of the three Cullenian types of continued fever, or to remittent fever. There is some difficulty in assigning its true place to one particular variety, which, under the name of yellow fever, has deservedly attracted great attention, on account of its frequency in various quarters of the world, as well as the peculiarity of its nosological characters. But it is in all pro- bability nothing else than a remittent, possibly, however, sometimes a typhoid con- tinued fever, with incidental or secondary accompaniments. There is also some difficulty in assigning a true place among primary fevers to those disorders, which have been termed in modern times gastric fever, and gastro-intestinal remittent. It seems well ascertained that the same irritations, which will excite local inflammation in the stomach or intestines attended with symptomatic fever, may also at times excite the febrile state independently of positive inflammation. This happens particularly in the irritable constitutions of children, but may also occur in the more robust habits of adults. The fevers thus arising may generally be distinguished from the primary fevers of the continued type unconnected with a local cause in the body, as well as from intermittents, and those commonly ranked as remittent fevers. But they tend in various circumstances to assume the form, sometimes of one, sometimes of another of these fevers; and are occasionally with difficulty distinguished. In a nosological arrangement, they form the passage, as it were, between primary fevers and febrile inflammations; and will be so considered in this work. Local Diseases in Fever.—Fevers seldom present themselves in actual practice with the simple characters, which, for the sake of precision, have been supposed in the preceding statement. The phenomena described above constitute the broader features by which they may be grouped in genera and species, for the purpose of convenient classification. But in special cases each kind of fever presents compli- cations, by which its essential characters may be more or less obscured, and which become most important objects in the treatment—more important, frequently, than the febrile state itself These complications seem to arise from one organ or set of organs being dis- turbed in their function beyond the rest, owing to constitutional predispositions, or other incidental co-operating causes. There is scarcely any end to their multiplicity. But by far the most frequent and the most important of them may be classed under the general head of local inflammations; and the greater part of the remainder under that of local irritations. Local inflammation confessedly, and in all proba- bility local irritation also, may subsist as a primary affection, giving rise to the fe- brile state as symptomatic or secondary to the local disturbance. But there can be as little doubt that such local disorders may likewise prevail incidentally in the course of primary fevers; that, although occasionally absent, their presence is, on the whole, the more general rule. Local inflammation, in particular, has even appeared to some modern cultivators of pathology, to be so invariable an accompaniment of what are called primary continued fevers, that they have been led to call in question the existence of any true primary fever, and to maintain that fever of every kind is constantly a symp- tomatic affection—a phenomenon secondary to inflammation in some special organ. The doctrine here alluded to, which has gained not a few converts in this country, and which, on the Continent, but especially in France, seems at the present time to predominate, is of so much consequence, both as striking at the very root of the theory of fevers previously current, and also as involving practical precepts of high importance, that a necessity arises for considering the subject in the present place in some detail. And the necessity becomes not the less urgent, if it be true, as appears highly probable, that the doctrine in question, however spacious, and however widely disseminated, is in reality untenable, being founded, like many other hallucinations in physic, upon narrow, though so far as it goes, correct enough, observation. 126 GENERAL DOCTRINES OF FEVER. Nature of Continued Fever.—-It may be well to introduce this topic with a short historical sketch of the principal opinions which have at different times been held of the nature of fever. A preliminary statement of these opinions can scarcely fail to have at least one good practical tendency. The picture thus presented to the mind, of the successive revolutions of sentiment that have taken place as to the theory of fever, of the ingenious absurdities which disfigured the early history of medicine, and of the plausible, yet not less visionary substitutes, which the au- thorities in every new era of medical science have devised, rather to the discomfiture of their predecessors than to the stability of their own credit, should teach due caution in adopting the still newer devcies of the present day, even though they do seem to be based on the sober discoveries of a faithful system of generalization, guided by a sound pathology. The ancient physicians were naturally led by the more prominent and tangible phenomena of the disease, namely the altered state of the several excretions, to imagine that fever essentially depends on a morbid state of the animal fluids. This doctrine, espoused at the revival of letters in the fifteenth century, acquired soon afterwards a more definite shape under the speculations of the alchemysts; and fever was held to be the result of a contest between acid and alkali within the body. For a long time afterwards, the fluids or humours were almost alone looked to for an explanation of the phenomena of fever; and hence the followers of the doctrine then in vogue have usually been designated humoral pathologists, or Humouralists. The doctrines of Humouralism held undivided sway over the minds of phy- sicians, in one shape or another, till the close of the seventeenth century. About this period they constituted a part of the theory of Stahl, who maintained that fever arises from plethora or fulness of vessels, and cacochymia or a depraved condition of the fluids; that it consists essentially of an effort of nature to get rid of these morbid states; and that the effort is accomplished under the direction of a soul —autocrateia, or governing principle within the body, which acts without any phy- sical necessity, and purely through its own intelligence. The theory of Stahl obtained wide circulation; like the doctrine which it displaced, it gave rise to grave practical errors. The views of the alchymists engendered a vain confi- dence in chemical remedies, for neutralizing or otherwise correcting the morbid condition of the fluids. The views of Stahl, by assuming the intervention of a free agent within the body, or an inherent vis medicatrix, inevitably led to an undue reliance in nature alone for the issue, and to the adoption of what has been aptly termed the medicina expectativa. So extravagant was the length to which his followers carried his principles in this respect, that some of them even established the sincerity of their creed by declaring their opinion that fever is a salutary operation, which scarcely merits the name of a disease—" ne quidem morbum vocari merere." The attempt made by Stahl to call in the aid of an intelligent governing prin- ciple to account for the phenomena of fever, probably gave rise to the first de- cided improvement in this branch of pathology, which consisted in some share of influence being allowed to the operations of the nervous system. For this step, as well as for the delivery from the trammels of a pure Humouralism, medicine is mainly indebted to Hoffman. Hoffman maintained that fever con- sists in spasm of the capillaries, which engenders re-action of the circulation as the means by which the spasm is to be overcome; and he referred the cause of spasm in the capillaries to some morbid affection of the nervous system. In consequence of looking chiefly to an altered state of the solids as the essence of fever, Hoffman and his followers have usually boen termed Solidists. To this theory Cullen afterwards gave more precision, by maintaining that the first inci- dent in the chain of sequences constituting fever, is a depressed state of the brain and nervous system; that spasm of the extreme capillaries results from this de- pression; and that re-action of the circulation, with its accompanying phenomena, is an effort of the system to overcome the spasm. The Cullenian theory, in a NATURE OF CONTINUED FEVER. 127 modified form, continues still to be the prevailing creed of those who adhere to the tenets of Solidism, and who believe at the same time in the existence of pri- mary or essential fever. Although the eminent reputation of Hoffman and of Cullen quickly attracted crowds of proselytes to the doctrines of Solidism, the ranks of the Humouralists were still by no means deserted. About the same period, Boerhllave, while adopting the principles of Solidism for the basis of his opinions, nevertheless admitted also the co-operation of chemical changes of the fluids in producing fever. Even Cullen himself allowed that, in certain circumstances, the fluids underwent morbid changes; but, in accordance with the principles first clearly propounded in the preceding century by Buglivi, he held that these changes were the consequence, not the cause, of the disease. In recent times an attempt has been made to revive the humoral pathology by a more accurate chemical examination of the fluids, and in particular of the blood. The facts which have been ascertained certainly seem to show that a morbid state of the blood may perform an important part, in developing some of the phenomena of fever. But the discoveries thus made are very far from bearing out the conclusion which has been drawn from them by some of the cultivators of this line of inquiry, for ex- ample by Dr. Stevens, that fever is entirely and fundamentally owing to the changes in question. So much attention has of late been drawn to the investigations of Dr. Stevens, and the facts on which his theory is founded, as well as the practical conclusions to which it leads, are of such a nature that it is entitled here to more particular notice. According to his observation, confirmed by that of other practitioners in hot climates, the blood in the marsh-remittent of the West Indies, and in yellow fever, which he considers a variety of infectious typhus, undergoes important changes in constitution. Even for days or weeks before the disease breaks out, the blood, in persons who have been for some time exposed to the poisonous effluvia, is usually dark, its serum brownish or yellow, with colouring globules precipitated through it, and its venous tint incapable of being thoroughly turned to arterial red by contact with air or various salts. These morbid characters Dr. Stevens seems to suppose, though he no where states so categorically, are owing to a diminution of the saline ingredients of the blood—those ingredients which he was the first to prove, by a set of very interesting experiments, to be essential for a healthy process of arterialization in the lungs. As the disease forms and advances, this morbid condition of the circulating fluid increases. The salts become less and less abundant; and, in consequence, the blood becomes progressively darker, the serum more coloured, the clot looser and looser, like ill-made current-jelly in consistence, and the modena tint of the venous blood less and less capable of becoming florid under exposure to air or saline solutions, till at length what is found in the dead body undergoes no change with either agent, or even with both together. These progressive changes he maintains to correspond invariably with the progress of malignant symptoms. And, on the contrary, it is alleged, that if the morbid state of the blood is encountered in time by the administration of natural non-laxative salts, allied to those usually found in the blood in its healthy condition, this fluid quickly recovers its healthy characters, amendment speedily ensues, and the mortality from one of the severest scourges, of man in hot climates is reduced to a mere insignificant fraction. Dr. Stevens's theory therefore is, that the poisonous miasma of marsh-remittent, and the infec- tious effluvia of yellow fever, alter the condition of the blood, especially by re- moving its saline ingredients; that this diseased state is the cause of such fevers; and, more particularly, that its gradual increase is the occasion of all the malig- nant symptoms, and of death. But he does not confine his inferences to the fevers which he has practically investigated. He holds in general terms, that " all essential or idiopathic fevers are primarily produced by a diseased state of the whole circulating current." (Observations on (he Healthy and Diseased Properties of the Blood, p. 148, 1832.) 128 GENERAL DOTRINES OF FEVER. It is impossible to enter here into the facts and arguments by which these views have been supported. Let it suffice, that the humoral pathology has thus been for the first time placed on something like a substantial basis. Dr. Stevens's researches go to prove, that the fevers of the West Indians originate in a diseased state of the blood. Propositions so important, however, cannot be adopted without strong con- firmation. This they have not yet received from his transatlantic brethren, though his book has been before the world upwards of six years; and, meanwhile, they cannot but be viewed with distrust in Europe, when it is found, that, contrary to his genera] inference, they will not apply to fevers universally, but are at variance with what is observed in the typhus of Great Britain. For the blood in British typhus presents no marked disease at the beginning; its saline matter, though it diminishes as the disease advances, does not decrease out of proportion to the other ingredients, more especially the colouring principle; and, in the worst cases, to the very last, nay, even after death, the dark venous tint of the blood readily un- dergoes the usual change to arterial red under agitation with air, if that experiment be properly managed. But farther, it certainly appears not a little extraordinary, that this theory should have been propounded in regard to the fevers of the West Indies, without actual experimental proof of the fundamental fact, a diminution, and disproportionately great diminution, of the saline materials of the blood Nothing could have been easier to determine by analytic experiments; yet there is not a single analysis of febrile blood in the author's whole book, nor is it any where stated that such was ever made; and the loss of the salts of the blood is allowed to rest merely on inferential evidence or simple asseveration. On the whole it may be strongly suspected, that, like many of his predecessors who are blamed by him for the same error, Dr. Stevens has mistaken effects for causes. That important changes occur in the blood in the course of fever was partly known before by vague observation of its sensible qualities, and is now fully substantiated by his researches, and the experimental inquiries of Dr. Reid Clanny. But the alterations which have been hitherto ascertained, have by no means been proved to precede the fever. They are distinct, at least, only after the disease has prevailed for some length of time; they certainly become greater and greater as it advances; and consequentiy the presumption is, that they are its effect, and not its cause. It seems highly probable, that a careful investigation of the state of the blood and secretions, among the other secondary phenomena, will lead to important reformations of opinion, as to many pathological details connected with fever. But the attempt to base a revival of the humoral pathology in its full force upon late chemical discoveries is premature, to say the least of it When the reputation of Solidism, and of the theory which refers fever to spasm of the capillaries was at its highest, a totally different doctrine was pro- pounded by Dr. Brown, the countryman, and would-be rival, of Cullen. Dr. Brown supposed that all external agents possess the property of stimulating a power inherent in the animal body, which he termed excitability ; that the result of their action, when natural in degree, is health; that inordinate excitement produces fever, by causing exhaustion of excitability, or what he called direct debility; and that defective excitement has a similar effect, by occasioning accumulated excitability, or, in his languge, indirect debility. Although this hypothesis presented much of the plausibility and flightiness which are apt to mislead imaginative minds, it never gained over many advocates in Britain. In Italy, it was for some time current But there, as here, it was found to lead to the pernicious practice of treating all fevers alike by stimulants; and the observation of the injurious effects of this prac- tice in some epidemics gradually overturned the doctrines whence it emanated. The present century had scarcely dawned, before the sentiments of physicians as to the nature of fever became so divided, that it is scarcely possible to say what were the prevailing principles of any of the great medical schools of Europe. It would require an undue extent of space to follow here the particular views which have been entertained by the chief authors, who have laboured in this branch of pathology during the last forty years. But it is necessary to take special notice of NATURE OF CONTINUED FEVER. 129 one doctrine, which forms, in various shapes, the groundwork of the principles maintained by a considerable proportion of pathologists for twenty-five years past, as well as in the present day. This is the doctrine already adverted to, which de- nies the existence of any primary or essential fevers, and holds them all to be merely symptomatic of some local disorder. The opinions preferable to this head deserve careful attention, not less on account of the eminence of the men who have promulgated them, than because they are professedly founded, where alone sound views of the nature of diseases can be founded, in the investigations of patho- logical anatomy. Early in the present century Pinel, the most acute and perspicuous of recent nosographists, while he advocated the doctrine of the essentiality of fevers, and carefully laid down the distinctions between those which are primary and those which are secondary to other disorders, nevertheless seems to" have opened the door for the new theory, by assigning to each species of primary fever, admitted into his classification, a concomitant local disturbance. He held that inflamma- tory fever is connected with disturbance in the general circulating system, bilious fever with disorder in the digestive organ's, a particular form of gastric fever with disease in the intestinal mucous follicles, nervous fever With derangement of the brain and nervous system, arid typhoid fever with depression of the gene- ral vital powers—thus obviously, in some measure, localizing the disease. Under the extended inquiries of pathological anatomists, it Was soon ascertained that the morbid appearances to be found in fever are far more numerous and im- portant than had previously been supposed; and, in the experience of some in- quirers, certain appearances were found, as they conceived, to occur so invariably, and to correspond so uniformly with symptoms of local disturbance from an early period of the fever, that they were induced to consider such pathological derangements to be connected With the febrile state as its real cause. In this way were formed, on the one hand, the doctrine of Dr. Clutterbuck, published in 1807, that fever is not a primary affection, but essentially a local inflammation, the seat of which is in the brain; artd, on the other hand, the theory of Brous- sais, announced in 1816> who, denying equally the primary nature of fever, maintained that its local cause is irritation, or inflammation, of the gastrointesti- nal mucous membrane. The principles of Clutterbuck have met with few adherents among authors, and with still fewer proportionally among practitioners. But the hypothesis of Broussais, upheld by the enthusiam and eloquence of its founder, and profes- sing to rest on the irrefragable evidence of anatomical facts, quickly spread far and wide, especially among continental physicians. ' And although it is now con- fined within a much narrower range, it is still believed in by many, artd may be truly regarded as the parent of several other forms, in which the doctrine ofnon- essentailism has been m'ore recently offered to the profession, anq in some quarters very generally espoused. Broussais—and in this respect his! followers have shown themselves his apt and faithful pupds—-took a summary view of gas- trointestinal derangement as the source of fever. For so long as he 6ould find any trace of morbid alteration of structure in the stomach or intestines, no matter how slight or vague the appearances might beJ, he felt at no loss in ascribing the general disorder to a local cause. Others, however, have not been quite so easily satisfied. They believe that Broussais saw with the vision of a theorist; that he discovered structural changes invisible to other unprejudiced eyes; and that he frequently mistook, for true morbid appearances, the pseudo-morbid re- sults of operations carried on in the body after death. In the course of testing, however, the accuracy of his doctirne by the means to which it owed its origin, namely, by appealing to the condition of the organs of the body after death, it was remarked, especially in certain localities, and above all in France, that one particular form of fever, more frequent and more impor- tant perhaps than any other, often presented itself in connexion with an un- doubted and formidable local disorder of the intestinal canal, which consists of Vol. I.—17 130 GENERAL DOCTRINES OF FEVER. inflammation of the solitary and conglomerate glands of the intestinal mucous membrane, leading on to ulceration. The existence of this disorder was indi- cated so early as 1762 by Roederer and Wagler of Gottengen in the course of an epidemic fever which prevailed in that city. It was again attentively observed in 1813 M M. Petit and Serres at Paris. But its anatomical characters and exact seat were first determined by M. Bretonneau of Tours, who considered it a distinct disease, and termed it Dothinenteritis (&0f*», a pimple, and etreptt, intestine.) And the first who investigated the relations of the local disorder with fever was M. Louis, the eminent physician of the Hotel Dieu at Paris. M. Louis has been led by his extensive and minute pathological inquiries to the con- clusion, in which very many pathologists, both among his countrymen and elsewhere, coincide with him, that the typhoid form at least of fever is always owing to inflammation of the glands of the intestinal mucous membrane; that dothinenteritis is the necessary anatomical character of typhus. Somewhat different from the doctrines of Broussais, as well as from those of Louis, yet based essentially on the tenets of the former physiologists, is the hypothesis of Professor Bouillaud. According to Bouillaud, fever is nothing else than an affection symptomatic of irritation or general inflammation of the circulating system; inflammatory fever, one of the degrees only of this irritative or inflammatory state; and the other forms of supposed primary fever mere compli- cations, arising sometime from inflammation of the alimentary mucous mem- brane and its mucous follicles, sometimes from irritation of the cerebro-spinal system, and sometimes from the introduction of putrid substances into the blood. This strange hypothesis, much vaunted at present among the author's country- men, and spoken of by himself with a degree of confidence which, with the exception of M. Louis, peculiarly characterizes the writings of the whole mo- dern sect of non-essentialists, is obviously derived fundamentally from the hypothesis of Broussais, and engrafted with the nosological classification of Pinel, as well as the doctrine of Frank respecting the origin of inflammatory fever in inflammation of the arterial system. Such are the leading opinions which have been entertained of late years by those who deny the existence of primary fever in general, or the primary nature of some of its forms. There can be no question that the essentialists, who looked almost entirely to fever in the abstract, neglected too much the local affections which attend it, and to which so great importance has been attached by many in recent times. But it appears not less clear, that the non-essentialists have raised the importance of these local disorders too high, and have been led, by an exces- sive confidence in the visible indications of pathological anatomy to underrate the importance of the general febrile state. There may be a doubt, whether all of the diseases which have been considered as fever by the numerous inquirers into this question, are really primary affections. It may in particular be doubted, whether the disorder described by Bretonneau and Louis is not a local disorder which stimulates fever. But at the same time it seems difficult for any one to survey dispassionately the whole facts, without coming to the conclusion, that fever is essentially a primary disease, and that most, nay possibly all, of the local diseases which have been pointed out as its real source are nothing else but se- condary affections. From this conclusion it is doubtful, whether the dothinen- teritis of Bretonneau may be excepted. The arguments by which the opinion here advanced may be supported, are chiefly the following:__ In the first place, examples of the three forms of continued fever—synocha, synochus, and typhus—occasionally present themselves without any appreciable sign of local inflammation during lrfe, or any corresponding appearance after death. Non-essentialists deny this, and say that the signs and appearances in question are often obscure, and have merely been not well sought for.— There is an end, however, of all argument with such controversialists. The symptoms and appearances of local disorder, assigned by non-essentialists as the cause of fever, are now well enough known to every scientific physician, and are frequenUy seen by every practical man who turns his attention to the pathology NATURE OF CONTINUED FEVFR. 131 of fever, more especially in great hospitals. The argument advanced above is nevertheless still found to stand good; and the charge of wilful blindness may be met in the same strain by a charge of wilful delusion of sight Secondly, the greatest proportion of cases of pure fever occurs in that form of it, where local in- flammation would naturally be expected to be most frequent that is, in synocha. Thirdly, the greatest proportion of cases of concomitant local inflammation occurs in the circumstances, where exposure to the causes of fever is most asso- ciated with exposure to the causes of local inflammation. Thus, instances of pure fever are proportionally much more frequent among the better ranks than among the working-classes; and that there may be no fallacy in this argument, , from the possibility of the kind of fever being different, it may be added, for the sake of limiting the statement, that the fact is observed to hold remarkably in respect to medical pupils and practitioners, who take fever by infection while at- tending fever patients in hospitals and dispensaries, and where no doubt whatever can exist as to the identity of their disease with that prevalent among people of lower condition. Thus, too, instances of pure fever are much more common among cases of relapse, than among first attacks; a circumstance quite unaccount- able on any other principle, except that local inflammation is secondary to fever, and arises often from simultaneous exposure to the cause of fever, and to the causes of inflammation. Fourthly, in a great proportion of instances, where local inflammation does occur in fever, it is secondary in point of time. It does not occur till the fever is fully formed; at least signs of its presence cannot be de- tected for some time afterwards, and often not for a very long period. As a co- rollary from this fact it would follow, according to the doctrine of Essentialism, that local inflammations are least frequent where the fever runs a short course; and this is actually found to be the case. Fifthly, where signs of local inflammation do show themselves, they often abate and disappear, without the general fever being in the slightest degree subdued or prevented from running its usual course, though that may be very long. Sixthly, on the contrary, the symptoms usually considered essential to primary fever may gradually disappear, and yet the local inflammation may continue with its peculiar signs, and come independendy to one of its customary terminations. Lastly, local inflammation of every sort may occur during fever; and, nevertheless, the grand features of the febrile state are essentially the same. We perceive the signs of chronic or of acute inflammation developed in one or another of almost every important internal organ of the body; but still, in a genuine case of fever, no experienced physician can be at any diffi- culty to point out other symptoms common to all, and not necessarily connected with inflammation of any organ. The conclusion seems irresistible, that there is something else in the disease independent of the local disorder. The general fact here adverted to has been the evident source of much embarrassment to the non-essentialists, since they cannot agree among themselves, what is the precise local seat of the cause of fever, some assigning the brain as its seat, some the glands of the intestine mucous membranes, some the mucous membrane itself of the whole gastro-intestinal canal, and some the general circulating system. The statements of fact here made are consonant, it is apprehended, with the experience of every British physician, who has been practically conversant with the phenomena of continued fever, as they have been presented on the great scale in the hospitals of this country during the last twenty years, since the appear- ance of the great epidemic of 1817. At all events, nothing has been stated above which has not been verified again and again, during that period, throughout the repeated epidemics which have prevailed in Edinburgh. The epidemics of fever, which have occurred in that city during the interval in question, have presented a very great variety of type or constitution, having gradually varied from the in- flammatory form which characterized the earliest epidemic, to the typhoid cha- racter which is at present (1838) dominant. The opportunities of observation may, therefore, be safely said to have been peculiarly favourable. The facts are as already given. The result, it may be added, has been, that not a single ob- 132 GENERAL DOCTRINES OF FEVER. server, who has enjoyed these opportunities throughout, is to be found in the ranks of the non-essentialists. It may be granted, that truth is not to be put down by authority, however consentaneous. Yet, nevertheless, a circumstance of this kind is not without its weight in the argument, more especially when it contrasts singularity with the result as to medical opinion in other great cities, such as Paris, where physicians have plainly formed their conclusions regarding the nature of the fever in the abstract from observing the characters ot a single form rarely presented in the epidemic shape. The arguments thus adduced against the supposed dependence ot fever on local disorders at large are equally applicable to each particular disorder, which has of late been pointed out by pathologists as its cause. They may be applied, for example, to the dothinenteritis of Bretonneau, the only cause, according to M. Louis and many others, of true tvphoid fever. This local affection, though com- paratively rare in Edinburgh, is well enough known to every practitioner of ex- perience as an occasional accompaniment of typhoid fever, especially in times when there is an epidemic tendency to diarrhoea and dysentery. It has been re- cognised by the same symptoms during life, and ascertained by the identical appearances after death, which have deservedly attracted so much attention in the French capital. But it has proved invariably secondary in point of date: its appearance and disappearance in special cases have repeatedly been observed to exert no influence on the essential features of the general febrile state: it has been occasionally seen to continue, with its proper local signs, long after the general fever had come substantially to an end, sometimes in that case undergoing a cure like the fever before it, sometimes on the contrary proving fatal; it has been met with precisely in the circumstances in which cases of apparently pure fever were at the same time engendered; that is, in families suffering generally from typhus without any intestinal disease; in cases where, judging from the symptoms and morbid appearances it was entirely wanting, which cases have uniformly formed an overwhelming majority, the general fever has been precisely of the same cha- racter, and very often precisely the same in degree, as where the local disorder was present: and, in conclusion, the intestinal disease has repeatedly presented itself in groups;—the constitutio dothinenterica, to speak in nosographical lan- guage, has repeatedly appeared and disappeared as a subordinate or intercurrent epidemic in the course of the more general epidemic—typhus, without the great features of that epidemic being altered in any material respect.* The errors of pathologists in investigating the question of the primary or secondary nature of fever seem to have mainly arisen from a circumstance, to which several other important errors that have lately gained currency are equally owing, namely, from limited observation, extensive enough perhaps in one sense, but limited in so far as it comprised experience of the phenomena of the disease in one locality only, and often too in one epidemic of that locality. The fate of the preceding theorists holds out small encouragement to any au- thor of the present day to imbody his own views of the general doctrine of fever. But some statement of the kind is nevertheless necessary for imparting a thorough * The writer of this article feels equal delicacy in avoiding, as in making, allusion to the result of repeated coversations, which, in common with Dr. Tweedie, he had lately the plea- sure of enjoying with iff. Louis, the most formidable adversary that the doctrine of the pri- mary nature of typhus has yet encountered. But, on the whole, ho thinks it best to state as his impression—without the most distant intention, however, of holding M. Louis pledged to the statement—that the views of that eminent and most candid pathologist have undergone some change since the publication of his last writings on the subject of fever; that, while he still holds the intestinal affection to be the anatomical character of true typhus, a local dis- order essential to his vraie affection typhoide, he admits that in London and Edinburgh we have a totally different disease, which is closely similar as to the character of the general fever. British pathologists will, it is apprehended, insist generally on larger concessions, and will maintain that this different disease is nothing else than the primary disease, or true typhus, and the other a secondary or intercurrent affection. NATURE OF CONTINTJEDFEVER. 133 idea of the spirit in which he communicates details, because no man peihaps ever wrote or practised in fever, without being more or less guided by one doctrine or another. The theory of fever, then, which seems not consonent with the whole facts, with the general sentiments of the Profession, especially in Britain, and with a sound and prudent practice, is probably the following.—Fever is an essen- tial or primary disease. The first appreciable event in the chain of sequences constituting fever is a functional injury of the nervous system. The only essen- tial or invariable consequence of this affection is functional derangement of most of the important organs of the body, but more especially of the brain, the circu- lating organs and fluid, the alimentary canal, and the skin. The characters of fever vary in some measure from year to year, and in different places, owing to unknown causes, which, for convenience, have been included under the generic term " epidemic constitution." The variations in its character, constituting va- rieties of primary type, probably depend on differences in degree in the primary functional derangement of the nervous system. Other variations, constituting in the undue development of special local disorders, whether functional merely, or passing into the organic character, or truly organic, depend partly on epidemic constitution, partly on manifest concurring causes acting at the moment of inva- sion of fever, or in its course. The changes which have hitherto been observed to take place in the blood and other animal fluids, are, like the local disorders, secondary and not primary: they may be the source of the phenomena remarked in the advanced stage of the disease, but they are not the source of the disease itself in the first instance. The preceeding principles are, in correct philosophi- cal language, matters of theory, capable of being decided by facts so soon as patho- logists are agreed respecting the facts. If we wish to advance a step farther, and tread in the regions of hypothesis, then it seems a reasonable doctrine, that the primary disturbance of the functions of the nervous system acts first on the ca- pillaries or extreme vessels of the surface, as well as throughout the internal organs, and produces, not spasm as was imagined by Hoffman and Cullen, but rather, according to modern views of the state of the capillaries in inflammation, a state of atony, relaxation, and distention, and consequently obstruction to the passage of the blood; that the disturbed state of the circulation is an effort excited by the stimulus of this obstruction for accomplishing its own removal; and that the disturbance of the function of circulation is variously modifiedjby the constant coexistenee and direct influence of the disturbance of the nervous functions. At all events there seems no question, that there are always two leading phenomena in fever, howsoever induced—disturbance of the nervous system and disturbance of the circulation: that, howsoever connected originally in the chain of sequences, they act and react on one another; and that their coexistence and reciprocal action, while they account on the one hand for many subordinate phenomena which are otherwise unintelligible, must on the other be kept constantly in view as modi- fying singularly the effects of remedies, and therefore regulating in many essen- tial respects the method of cure. Exanthemalous or Eruptive Fevers.—Modern nosologists restrict exanthe- matous fevers to certain febrile diseases accompanied with efflorescence of the skin (comprehending small-pox, measles, and scarlet fever,) and allied to each other in the following circumstances:—1.Though the eruption is of a defined character, it is preceded by a characteristic group of febrile symptoms, the fever pursues a defi- nite course, and the exanthema passes through a regular series of changes. 2. They occur only once (with very few exceptions) during life. 3. Almost all mankind are susceptible of them. 4. They are propagated by a specific contagion. 1. The defined character of the eruption, the remarkable combination of symp- toms which attends the eruption, and the precision with which the several changes or phases of each disorder occur, are most remarkable. The eruption of small-pox appears on the third day from the commencement of febrile commotion, and matu- 134 GENERAL DOTRINES OF FEVER. rates or culminates on the tenth. In measles the fever rages in the system for four days before its specific eruption is developed, and three days suffice for the com- pletion of its course. The efflorescence of scarlatina is perceptible on the second day, and begins to disappear on the fifth from the first occurrence or rigor of sick- ness. The course of the fever and the series of changes which the eruption under- goes "are alike fixed, and uniform, being in all important points uninfluenced by age, climate, season, or habit of body, and admitting only certain modifications from causes altogether unknown or imperfectly understood. 2. The second common character of the true exanthemata is founded on the law of non-recurrence. Immunity from second attacks of the same malady is a very re- markable principle in pathology. Mankind have by common consent attributed the power of conferring immunity from second attacks to three only of the many dis- eases to which we are liable—viz. to small-pox, measles, and hooping-cough. It constitutes undoubtedly a most important feature in the medical history of these disorders, and by virtue of it they are, to a certain extent, isolated from other mala- dies. The same property belongs, though in unequal degrees, to three other forms of febrile disease—viz. to yellow fever, to the plague, and to scarlet fever. It is more striking in yellow fever than in plague ; more observable in the plague than in scarlet fever; but in all, the susceptibility to future attacks is either greatly les- ened, or entirely removed, by once undergoing the disease. The doctrine of immu- nity from second attacks, though generally predicable of small-pox and measles, is even in those diseases, liable to certain exceptions, as will be more fully explained afterwards. 3. Universal susceptibility is the third character of the exanthemata. The ex- ceptions to this law, in the instances of small-pox and measles, are very few, and there is great reason to believe, that in many of these excepted cases, the inaptitude to receive the disease arises from temporary causes; and ceases in the course of a few months, or possibly not until after the lapse of years. The principle is not of such general application in the case of scarlatina. 4. The exanthematous fevers are propagated by contagion. The power of pro- ducing a contagious matter is one of the most striking characters of small-pox, and in the phenomena of inoculation we possess the most convincing proof of the truth of the principle. The evidence in favour of the possibility of inoculating, or rather of artificially exciting, the measles is strong, though still open to some objections. The instances of the spreading of scarlet fever by personal intercourse are so numerous and unequivocal, that no enlightened pathologist of the present day hesitates to ac- knowledge the fact. Some contagions develop themselves quickly, such as those of scarlet fever and plague, which generally require from four to six days for their incubation; sometimes, however, more especially in scarlet fever, the period has been longer deferred. Others as small-pox and measles, require nearly a fortnight for their perfect development. Some contagions, however, remain latent in the constitution for three, four or six weeks, but each of these respective periods is sub- ject to certain modifications, which will hereafter become objects of special investi- gation. Classification of Fevers.—According to the exposition formerly given, Fevers, in the most comprehensive sense of the term, may be divided into primary fevers, irritative fevers, eruptive fevers, and febrile or acute inflammations. Primary fevers may be subdivided into continued, intermittent, and remittent fevers ; to the last of which may be attached, as an appendix, yellow fever, until more precise information be obtained regarding its source and nature. Of continued fever it is sufficient to indicate three varieties or types—synocha, synochus, and typhus;—which may all occur either simple, or with complications. Irritative fevers are a less accurately de- fined class than any other, as they pass by insensible shapes into remittent or contin- ued fever on the one hand, and into the febrile inflammations on the other. But it may be convenient to arrange under this head gastric fever, gastro-intestinal remit- CLASSIFICATION OF FEVERS. 135 tent, and also hectic fever; the last of which, though commonly, is by no means ne- cessarily, associated with suppuration, and may be correctly considered as a fever from irritation. The arrangement will therefore stand thus:— Primary Fevers :— Continued Fever— Synocha, or Inflammatory Fever. Synochus, or Mixed Fever, Nervous Fever. Typhus, or Adynamic Fever. Intermittent Fever— Tertian. Quotidian. Quartan. Remittent Fever— Marsh-remittent, comprising probably Yellow Fever. Irritative Fevers :— Gastric Fever, and Gastro-intestinal Remittent. Hectic Fever. Eruptive Fevers : Small-pox. Measles. Scarlet Fever. ( 164 ) CONTINUED FEVER. Symptoms of continued fever.—Secondary affection.—Affections of the head—of the throat— of the chest—of the abdomen—of the skin.—Sequelae.—Relapse.—Partial rheumatism and ueuralgia.—Partial palsy.—(Edema.—Acute febrile inflammations.—Supervention of phthi- sis pulmonalis.—Mania.—Prevalence, duration, and mortality.—Anatomical characters.— Causes.—Prognosis.—Treatment.—Prophylaxis. Continued Fever may be defined nearly in the same terms with those formerly employed in the definition of fevers generally. It is a disease in which, after a pre- cursory stage of languor, weakness, and defective appetite, acceleration of the pulse takes place, with increased heat, great debility of the limbs, and disturbance of most of the functions, without primary local disorder, and without well- marked remissions. It has been already stated above, that none of these charac- ters is absolutely invariable. Thus the appetite is occasionally not at first affected: the strength is at times so little reduced in the early days, that a man in the inci- pient stage has been known to walk forty-five miles within as many hours; the pulse not unfrequently does not rise beyond seventy; the heat is often immaterially increased; the debility of the advanced stage may disappear for a time in connex- ion with active delirium; local inflammations frequently concur with the general fever, especially when fully formed; and very distinct remissions are often enough observed towards the commencement, and sometimes throughout the whole course, of the fever. The last invariable character is disturbance of the functions gererally; for it seldom happens that the functions of the digestive organs and of the skin are not essentially deranged, and the clearness and precision of the external senses impaired. Symptoms of Continued Fever.—There is but one way of taking a compre- hensive and simple view of the symptomatology of continued fever; which is, by considering first the essential phenomena of its three leading varieties or types, and then the phenomena which are incidental or accessory. It seems advisible too, that the symptoms of the three types be viewed in succession or close relation to each other; because they are, at least in the opinion and according to the experience of the writer, mere varieties of one fundamental disease, originating in the same causes, and constituted merely by differences in those obscure co-operating influences which are alluded to when we speak of epidemic constitution. This is the conclu- sion to which every one will arrive, who has had an opportunity of closely watch- ing in hospital practice a long series of epidemics, similar to those which have ra- vaged the city of Edinburgh between the years 1817 and the present time. For the disease has been clearly seen, during that interval, to pass very gradually from a type in which pure inflammatory fever was exceedingly common, first into one composed of the same fever in the early stage, and of adynamic fever in the advanced stage, and at length into a type of nearly pure adynamia or typhus, which has prevailed for a few years past. And these changes have thus gradually taken place, without any other essential alteration in the history of the disease, but espe- cially without any change in its apparent mode of propagation and causes. synocha, (Symptoms.) 137 Symptoms of Synocha.—It has become fashionable of late with medical au- thors to doubt or deny the existence of such a fever as synocha or inflammatory fever, or at least to limit it to warm climates, and to admit ephemeral fever alone as an exemplification of it in temperate countries. But this is a mistake, arising simply from limited opportunities of observation, and the disregard of epidemic differences occurring in different years and different places. In the Edinburgh epidemic of 1817-20, a fever purely inflammatory, or with complications, but al- together divested of the typhoid character, was so prevalent, that from a numerical statement kept for sometime by the writer, it formed between a fifth and a sixth of the patients in the infirmary and fever hospital. In the subsequent epidemic of 1826-9 the same form was observed, but by no means in so great a proportion; and since then it has gradually disappeared, and is now scarcely ever met with. There is no room, therefore, for the doubts which have been lately thrown over the accuracy of Dr. Cullen's classification and delineation of fevers, from the apparent impossibility of finding his synocha or inflammatory fever. In this, as in other respects, Cullen's delineations are true to nature, whatever may be thought of his spe- culations in regard to the proximate cause or essence of fever; and, indeed, little has been hitherto done to improve the leading features of his classification, and least of all by those who have slighted his admirable descriptions of disease. Synocha may be defined nearly hi the language of Cullen, a fever, consisting of a state of chilliness or rigour, succeeded by great increase of heat, frequent hard pulse, redness of the urine, little disturbance of the mental faculties, and tending in general to terminate by sweating. It commences for the most part abruptly. The patient is suddenly seized with an undefinable sense of feebleness, languor, and oppression, disinclination for food, sickness, and perhaps also vomiting, frequency and feebleness of the pulse—fol- lowed speedily by pain in the back, headach, a peculiar sense of weight or rend- ing in the limbs, coldness in the back, general chilliness, and often absolute shiver- ing, with paleness of the features, and the cutis anserina. When these symptoms have lasted for a period varying in general from one hour to half a day, the cold- ness passes off; the pulse, from being soft and fluctuating, becomes hard, sometimes full and bounding, often small, wiry and incompressible, generally very rapid, sometimes so frequent as 140, 150, or even 160; the tongue dry and covered with white or yellowish fur; the skin parched, red hot, often pungently so; the animal temperature elevated to 102°, 104°, and occasionally so high as 107°. At the same time there is increased headach, with giddiness, throbbing of the tem- ples, and flushing of the features; great undefinable uneasiness in the limbs, oc- casioning frequent change of posture; an intense sensation of heat; whiteness and dryness of the tongue, with urgent thirst and desire for cold liquids, but a total loss of appetite; constipation; redness and scantiness of the urine, often with a tendency to discharge it frequently; extreme irritability of the senses of sight and hearing, more especially remarked in the irritable constitutions of persons in the better ranks, so that in them the faintest light, and any regularly recurring sound are insupportable. An exacerbation commonly occurs in the evening or early part of the night, and a remission early in the forenoon, but the difference is fre- quently trifling. The fever is thus fully formed in general in the course of the first evening; but not unfrequently the hot stage is completely developed in an hour or less; and, on the other hand, it may be imperfectly presented till the se- cond day. There is not necessarily any local pain, except headach and a sense of soreness or rending of the back and limbs. Vomiting and sickness are sel- dom present, or at least troublesome, till the second or third day; are often wanting throughout most of the attack; and frequently are insignificant till blood- letting has been practised, after which vomiting is often frequent and severe. The faculties of the mind are for some days unaffected, except by restless- ness and anxiety, and they may continue undisturbed even during the whole course of the fever; but frequently after a few days, there is a tendency to de- lirium, and at times the delirium is active, and indicated by frequent incoherent Vol. I.—18 138 CONTINUED FEVER. talking, together with a disposition to roam Very often, however, the tendency of the patient to leave his bed, from mere febrile restlessness and desire of change of posture, is mistaken for delirium. Delirium occurs most frequently for a short time before the hot stage of the fever is about to be resolved. The blood from a vein is commonly very florid—sometimes, in young adults with high re-action, so unusually bright, that the surgeon is apt to imagine he has opened an artery instead of a vein. It coagulates in general firmly, with little separation of serum; but not unfrequently shows the buffy coat, contracted clot, and distinct separa- tion of serum observed in acute local inflammations. The terminations of this form of fever, are essentially three in number, abrupt departure in connexion with some critical discharge, gradual mitigation and disappearance, without par- ticular increase of any of the excretions or any adventitious evacuation, and gra- dual transition from the purely inflammatory character into the typhoid type. But when the last of these courses is pursued, the disease ceases to be synocha, and is characterized as synochus. A common course is gradual mitigation of the symptoms between the seventh and fourteenth days, sometimes without any cri- tical discharge, yet sometimes too in concurrence with occasional attacks of sweat- ing. If the fever lasts, however, much longer than seven days, it commonly puts on, sooner or later, the typhoid or adynamic character. If, on the contrary, there is decided amelioration earlier than the seventh, or even on the seventh day itself, the amendment usually becomes complete, and occurs in connexion, either with a profuse attack of sweating, or sometimes, though far more rarely, with an attack of diarrhoea, or of epistaxis. The most frequent, and by much the most remarkable, variety of this type of fever, is that which terminates ab- ruptly by sweating. Sometimes so early as the fourth day, very rarely earlier; most generally on the fifth or sixth, sometimes on the seventh or eighth, but sel- dom at a later period, the skin becomes moist, along with sudden abatement of the headach and jactitation; and a profuse discharge of sweat follows, which lasts for two, three, four, six hours, or upwards, and leaves the patient languid and ex- hausted, but otherwise almost free of every complaint, and, in particular, with the pulse at the natural standard. It is not uncommon to observe a sweat of four hours change the condition of a patient from all the tortures of an ardent fever, with the pulse at 140, to a state of complete repose and absence from all suffer- ing except from extreme languor, with the pulse at 70. In a few rare cases the fever is carried off in like manner by critical diarrhoea, or critical epistaxis. Con- valescence from an attack of fever of this kind is alwrays slow, several weeks be- ing requisite for restoration of the strength, even where the patient has not been more than five or six days under the proper febrile symptoms. Relapse too is common, and it usually takes place about the fourteenth day; nor does any care on the part of the patient to avoid the causes of excitement or fatigue, seem to have any tendency to diminish the chance of relapse. This commences, for the most part, with severe shivering; symptoms succeed similar to those already men- tioned, as characterizing the primary attack; and the disease is finally resolved by another fit of profuse perspiration, generally in the course of the third day from the re-appearance of rigours. Such is a sketch of inflammatory fever in its pure state, as it occurred in a considerable proportion of cases of epidemic fever, especially among young adults, both in Edinburgh and in other parts of Great Britain and in Ireland," between the years 1817-20, and likewise, though to a less extent, in the succeeding epidemic of 1826-9. In many instances, however, the disease was not altogether pure. More generally it was attended, in one part or another of its course, with symp- toms of local inflammation—most frequently in the chest, occasionally in the pe- ritoneum, more rarely in the larynx, often in the tonsils, seldom in the parotid gland, and very seldom in the head. Such local affections, of which catarrh, pneumonia, and pleurisy, were the most common, did not show themselves till the fever had lasted for a few days; they frequendy disappeared some time before the cessation of the febrile symptoms; and they were, for the most part, very synocha, (Symptoms.) 139 easily removed by general or even local depletion. In a few rare cases the local inflammation went on where the fever was checked. Rheumatic attacks were common during convalescence; but they were . seldom attended with any febrile disturbance of the circulation. Cases of pure fever were most frequent in young persons of the better ranks, who were not exposed to the ordinary co-operating causes of local inflammation. The synocha of hot climates seems not to differ essentially from the disease here described. The tendency to diaphoretic crisis, however, is less marked; there is not the same frequency of relapse; neither is it observed that relapse is apt to occur after a fixed interval, rather than at other irregular periods of conva- lescence. It is also said by Dr. Stevens, that it is never ushered in by rigours, and that the blood, though always unusually florid, never presents the buffy coat of inflammation. Farther, while the inflammatory fever of hot climates evidently arises from atmospherical vicissitudes, or such other causes, and independently of communication with the sick, the synocha which is described above often ori- ginates as unequivocally in infection, as will be more fully explained under the head of the Causes of Fever. Under the general denomination of synocha may be arranged the slightest of all febrile disorders of the primary kind—ephemera, or ephemeral fever, so named, because it seldom lasts much longer than a single diurnal revolution. This is the simplest of all febrile affections. Its characters have been already described and nothing farther need here be said on the subject. It is undoubtedly in general a primary affection, and often no apparent cause can be discovered for it. Fre- quently it originates under atmospherical vicissitudes during the irregular months of spring in these climates; frequently too, during the prevalence of ordinary epi- demic synocha, it seems to arise as if from an effort of the epidemic cause to invade a constitution seasoned by a previous attack; occasionally it is seen as the apparent effect of large doses of cubeb-pepper, given continuously as a remedy for gonorrhoea; but, most frequently of all, it is exceedingly difficult to discover any unequivocal cause for it. Synocha may pass by insensible shades, first, into synochus; secondly, into gastric or gastro-intestinal fever; and, thirdly, into the acute or febrile inflamma- tions. It is seldom difficult to distinguish idiopathic local inflammations from primary inflammatory fever; yet sometimes the diagnosis is obscure. The chief distinctions are, that in the latter the local inflammation is slight compared with the general febrile state; that it rises consecutively to the fever, and may cease without the latter disappearing or even abating; and that there is throughout the disease, but especially at the beginning, more oppression, nervous exhaustion, and restlessness, together with a peculiar expression of the countenance, which a practised person may for the most part readily recognise. Gastric fever is sometimes distinguished from synocha with great difficulty. The pyrexia, how- ever, is seldom so violent, nor the countenance so oppressed, nor the sense of rending and restlessness of the limbs so distressing; neither is there so marked a tendency to resolution of the disease by sweating; while, on the other hand, the tongue is more loaded with yellow sordes, or red and raw-looking—the local symptoms referable to the abdomen are generally more marked, though this is far from being invariably the fact—and there is usually a much more distinct ten- dency in the fever to put on the remittent type. There is never any difficulty in distinguishing true inflammatory fever from synochus; but the former passes insensibly into the latter, by the supervention of typhoid symptoms towards the commencement or termination of the second week; and, according to the degree of that secondary stage, the case may be regarded as belonging either to one type or the other. Symptoms of Synochus.— this is probably the most frequent of all types and forms of continued fever. It is essentially characterized by the disease commen- cing as cynocha and terminating as typhus. There are scarcely any cases of 140 CONTINUED FEVER. primary continued fever, which do not present an inflammatory stage of longer or shorter duration, and of more or less violence at the commencement; so that, perhaps, all continued fevers not falling under the purely inflammatory type, might be considered as synochus. But in nosological arrangements, as well as in practice, the term is usually, and in reference to treatment conveniently, re- stricted to such primary fevers as begin with a distinctly marked inflammatory stage like synocha, lasting for at least a few days, and not giving way to adyna- mic or typhoid symptoms till the beginning of the second week at soonest. Such was the general nature of the epidemic fever which raged in the United Kingdom from 1817 till six or eight years ago; and such too seems to have been the febris bellica of the Continent, which broke out in the large towns of Germany and other continental countries of Europe in 1814, subsequently to the French war; and of which, indeed, the British epidemic was probably a propagation. Under the same head may be classed most of the fevers described by English authors of the last century, under the name of nervous fever. The most remarkable ex- amples of it which have perhaps been ever seen, occurred in the British epide- mics of 1817-20 and 1826-9. For the inflammatory stage was often so well marked, that it was impossible to tell for some days whether the disease was to terminate as synocha, or pass on to the typhoid stage of synochus; while on the other hand, the typhoid characters of the advanced stage were often in those very cases so well developed, that no one, seeing the disease for the first time at this period, would have known from the symptoms that it had ever been any thing else than true typhus. In later years the inflammatory stage has become much less prominent; and in the generality of cases, at least in Edinburgh, as well as in other great towns, it has at present almost disappeared, and given place to typhoid symptoms from a very early period of attack. In describing synochus it seems unnecessary to enter into particulars. The de- tails of the typhoid stage are exactly the same with those which will presently be given under the head of typhus. Those of the inflammatory stage have been al- ready related at sufficient length under that of synocha. In synochus, as in syno- cha, the fever is sometimes simple, but much more frequently complicated, as in the latter, with local inflammation in the early stage. Later in the disease, when typhoid symptoms are formed, local inflammations and local congestions frequently appear as in typhus, and more frequently than these secondary disorders are ob- served to show themselves in the early stage. Yet even in the latter stage, second- ary affections are sometimes absent, so that we have a pure, uncomplicated, pri- mary synochus from first to last. Cases of this nature were clearly observed du- ring the British epidemics above referred to. The most common secondary affec- tions in this, as in the inflammatory form of continued fever are, in Britain at all events, inflammatory diseases of the lungs—pleurisy, pneumonia, but especially catarrh, often passing into bronchitis. The passage of synocha into typhus usually takes place, as already remarked, in the course of the second week. It is indicated by the pulse opening up as it were, becoming fuller, more compressible, though still often equallv jarring, and falling at the same time somewhat in frequency. The tongue also acquires a brown dry streak down the centre; the heat is less pungent, while the skin is equally dry; but, in particular, the muscular exhaustion increases greatly; the senses from being irritable become more obtuse than natural, especially the sight and hearing; the integuments, from presenting a bright red flush, acquire a dingy reddish-brown tint, of the nature of congestive redness; and there is a marked tendency to doze, sometimes intermingled with slight muttering delirium. These changes gradually lead on to the state of true typhus in its characteristic form, which will now be described. Symptoms of Typhus.—As synocha passes by insensible shades into svnochus, so the latter passes insensibly into typhus. The early stage of inflammatory symptoms may be observed in different cases to be shorter and shorter in dura- tion, and more and more intermingled with nervous depression or adynamia, till typhus, (Symptoms.) 141 at length we have a fever, in which the inflammatory re-action is never charac- teristic, and is followed at an early period even of the second week by the same phenomena which constitute the latter stage of synochus. The term typhus has gradually acquired of late a rather vague signification. In consequence of passing into prefessional language, it has become gradually to signify, in familiar speech, infectious fever; and in this signification it is used even by many physicians. In correct nosographical language it should compre- hend only those fevers where the characters of adynamia, or nervous depression, present themselves as the predominant feature of the disease from first to last. But in practice the term has been extended from this very restricted meaning, so as to embrace that far more numerous class of cases where such characters show themselves before the close of the first week, and where the earlier stage of pure inflammatory action, although present, is not well marked. In this sense typhus is scarcely less important than synochus in point of frequency. In many epi- demics it is the ruling form; and, for a few years past, in Britain generally, and especially in Edinburgh, it has constituted almost the sole prevailing type. Typhus may be defined, a fever characterized by a compressible, rather fre- quent pulse, little increase of the animal temperature, extreme langour and de- bility, and much disturbance of the menial functions. Some, following the ex- ample of Cullen, indicate as another character its origin in infection, which, however, is by no means peculiar to this alone among continued fevers; neither is there a certainty, that it is an invariable character even of typhus. The most remarkable circumstances in typhus are the great exhaustion of the muscular strength, and the torpor of the mental functions, often mingled with delirium. The latter character is undoubtedly the foundation of its name, which is derived from rv