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COLLINS, PRINTERS. fever does not admit of a strictly correct and unobjectionable defini- tion ; since there is not a single symptom which is invariably present, and which can be regarded as absolutely essential to its existence. Boerhaave collected together, from a great number of authors, all the symptoms which had been observed in fevers. He then struck from this list all those symptoms which did not appear in all, but only in certain modifications of fever—retaining such only as, by the common consent of authors and his own observations, were found to and hence, perhaps, it is, that fevers are called diseases by Hesiod, and that Horace calls all diseases simply fevers, when they rushed out of the box of Pandora— (Post ignem ectherea domo Subductum, Macies, et nova febrium Terris incubuit cohors.',; Van Swieten's Com., vol. v. p. 1 GENERAL PATHOLOGY OF FEVER. 19 be present in every instance of fever. The result was, that only three symptoms were left standing —namely, a quick and frequent pulse, preternatural heat of the surface of the body, and a sense of cold or chilliness in the commencement. But he might have gone farther, and struck from his list these symptoms also ; for it is quite certain that cases of fever do occur in which there is neither preternatural quickness and frequency of the pulse, nor an increased temperature of the surface of the body ; nor is a sense of chilliness, though perhaps the most constant of all the febrile symptoms, universally present in the initial stage of fever.* Notwithstanding the great difficulty, or rather impossibility, of giving a strictly unexceptionable scientific definition of fever, yet the train of phenomena which this state of disease presents under all its modifications—varying more or less in their concomitance and succession—offers, upon the whole, a character sufficiently distinct and definite for easy and certain recognition. Pathologists have divided fevers—according to the mode of their development—into idiopathic and symptomatic, and the propriety or impropriety of this division constitutes, at the present day, one of the most important, and warmly contested subjects in pathology. By the former class, are understood those fevers that are developed and sustained by causes, which produce a general morbid state of the system, independent of local inflammation or fixed irritation. Those who admit the existence of such fevers, suppose that the re- mote febrific cause produces a deleterious impression on the sentient extremities of the part upon which it acts, which, deranging function after function, according to the catenation of the organic sympathies, finally results in a state of general disease, characterized by the ordinary phenomena of fever ; or, as they presume, the remote cause may gradually change the healthy character of the circulating blood, which, acting as a morbific irritant on the heart and arteries, gives rise to febrile reaction. Many eminent pathologists, on the contrary, contend that such fevers can have no existence; and that all febrile excitement is purely symptomatic, and of course essentially and wholly dependent on a pre-established local irritation or inflammation. According to these views, the direct influence of the remote cause of fever is limited to the production of the primary local inflammation or irritation, the subsequent pyrexial phenomena being the result solely of this pri- mary local affection ; in other words, the secondary and sympathetic excitement of the pre-established focus of irritation. At the head * [In malignant epidemics patients often die in the forming stage of disease, before febrile reaction is manifested. Nevertheless the case is pronounced to be one of the prevailing fever. Congestive fevers are described by many authors in which there was never any development of external heat or excitement of the pulse. It is questionable, however, whether this is not too extensive an applica- tion of the term. If every condition that precedes or accompanies a fever is to be designated by the same epithet, there will certainly be no occasion for the exten- sion of nosology.—Mc] 20 GENERAL PATHOLOGY OF FEVER. of those who advocate the exclusive symptomatic nature of fever Broussais, who, whatever may be thought of his peculiar doctrines in relation to this subject, has manifested a professional zeal, ana an activity and acuteness of intellect, which have justly piacedmrn high among the " greater lights" of our profession. Not satisnea, however, with the adoption and defence of the general doctrine oi the universality of symptomatic fever, Broussais contends that tne inflammation or irritation whence the febrile sympathies radiate as from a focus, is almost universally located in the mucous membrane of the alimentary canal; and hence gastro-enteritis is with mm the fons et origo of febrile phenomena. That fever is a very common result of local inflammation, is unquestionable. So intimate are the sympathetic relations between all the various parts of the animal body, that no structure or organ can be strongly irritated without causing a sympathetic irritation in other organs or structures. If the primary irritation involve the sanguiferous capillaries, the irritation will be communicated by sym- pathy to the general vascular system, and fever will be the result; but if the local irritation be purely nervous, it will be diffused, and as it were locked up in the general nervous system, and give rise to convulsions, or some other form of general nervous affection. Without doubt, too, inflammation of the mucous membrane of the alimentary canal is much more common in febrile diseases than was formerly, and by many, is still supposed. It is even probable that in many instances of fever, such an inflammation constitutes the primary and essential cause of the febrile phenomena. This is, perhaps, most apt to be the case in those instances of fever which result from the combined agencies of impure and indigestible diet and atmospheric vicissitudes. But although we may admit the correctness of these observations, yet to refer all fevers, remitting, intermitting, and con- tinued, to gustro-enteritis, is as remote from truth as it is detrimen- tal in its influence on practice. The advocates of the physiological doctrine, as it is called, endea- vour to support their sentiments in relation to this subject, by the phenomena detected on post-mortem examination, and by arguments founded on physiological principles. It is affirmed that marks of inflammation almost universally occur in the mucous membrane of the alimentary canal, in subjects that die of febrile affections. The capillary vessels, to a greater or less extent, of this membrane, it is said, are found injected ; and in many instances other and less equi- vocal traces of previous inflammation are discovered. Admitting that such manifestations of inflammation are as universal as they are asserted to be, is there not much reason to believe that, very frequently at least, the inflammation supervened during the course of the disease, as a consequence of the fever, rather than that the inflam- mation was pre-established, and became the immediate excitin» cause of the febrile phenomena ? We frequently see inflammations&super- vene in parts exposed to observation many days after general fever has been fully established. Indeed, when it is considered that in all febrile affections, the secretions which are poured into the intestinal GENERAL PATHOLOGY OF FEVER. 21 tube are unnatural and vitiated—that the process of digestion is sus- pended, or much impaired, and consequently, that fermentation and decomposition of the contents of the stomach and bowels are espe- cially favoured—is there any cause to wonder that we should so often meet with traces of inflammation in the digestive organs in those who die of febrile affections ? The Broussaian mode of treating fevers, although especially meant to obviate such inflammations, ap- pears to me, in one respect, well calculated to favour their occurrence. The almost total proscription of purgatives from the list of our reme- diate means for the treatment of fever, so far from lessening the ten- dency to gastro-enteritis, tends, I conceive, in general, to an opposite result. In a recent work by Bouillaud, there are upwards of sixty cases of fever reported, in not a single instance of which was there a purgative medicine administered by the mouth. In all of these cases, however,marks of inflammation, and in the majority ulcerations were detected in some portion of the mucous membrane of the bowels. That this should have been observed, will not appear strange, when it is considered that in all the cases, most of which continued from three to four weeks, all the acrid and vitiated contents of the intes- tines were suffered to remain, undisturbed, to act on their delicate fining membrane. To one not thoroughly imbued with Broussaism, it does appear strange that any one should withhold a laxative, under the appre- hension of its causing injurious irritation, and yet suffer, without any such fears, the most irritating substances to lie quietly in the bowels. It is true, laxative lavements were repeatedly resorted to in these cases, but that these did not disturb or remove the acrid materials which were inclosed in the bowels, is abundantly manifest from what Mr. Bouillaud himself has stated. After having gravely told us that in all the cases he describes, the traces of mucous inflamma- tion in the bowels were tres pro nonce, he states that "in general the stomach and small intestines were filled icith a yelloivish or green- ish bile, and that the residue of the alimentary substances which toere found in the small and large intestines, invariably exhaled an intolerably fetid smell,and frequently exhibited the consistence of mustard. This residue, mixed with various fluids secreted in the intestines, appeared to have undergone a complete process of putrefactive decomposition, as was evident from the extreme. offensiveness of the smell, and the fetid gas which distended the bowels." "* Can it be reasonably supposed that the transient and moderate irritation of a purgative in these cases would have been more in- jurious than the constant impressions of the acrid and irritating substances which were so long left in immediate contact with the bowels ? It is thus, it can hardly be doubted, that many instances of gastro-enteritis, so abundant in the practice and dissections of the Broussaian school, are developed. Were laxatives employed with due moderation, it is probable, that the so much dreaded gastro- * Traite Clinique et Experimental des Fievres. Par J. Bouillaud. Paris, 1826. 22 GENERAL PATHOLOGY OF FEVER. enterite would, in some instances at least, perhaps in ma"y' prevented, and the world deprived of a large proportion ol tnos triumphant demonstrations which are continually brought out formidable array in support of the physiological doctrine. As a further offset to the evidence adduced from post-mortem examination, it must be observed, that so far as the mere redness or injected state of the mucous membrane is concerned, we can draw no certain inference as to the previous existence of inflammation in this structure. That these phenomena are frequently the result ol changes effected in articulo mortis, ox post-mortem, is fully demon- strated by the observations of Mr. Yellowly and of Mr. Seeds.* * " It must have happened to every one," says the former of these writers, " accustomed to the examination of dead bodies, to see appearances of vascular injection in the villous coat of the stomach. Such appearances have very fre- quently been referred to inflammation, but they have probably been but little studied. I have several times been present at the examination of bodies, where the vascularity of the villous coat of the stomach was so considerable as even to give rise to suspicions that the appearance had been produced by something deleterious. I was therefore induced to embrace frequent opportunities of view- ing the state of the inner surface of the stomach, and I so often found in it the appearances alluded to, as to induce me to imagine, that the opinion which is commonly entertained of their being marks of disease, is not well founded. In persons suddenly destroyed, when apparently in perfect health, he found the mucous membrane of the stomach highly injected.'7 Mr. Seeds, too, found that in animals bled to death, the membranous structures frequently exhibit a state of injection which might, at first sight, be readily mistaken for inflammation. It is well known that the arterial tubes possess a power of contracting to a considerable extent, by what Bichat calls the contractility of texture, and that this power is not limited to the period of life, but continues some time after death. It is equally ascertained that the capillaries are endowed during life with a peculiar degree of sensibility which causes them to resist the entrance of such fluids as they are not destined to convey in the performance of their natural functions. This peculiar sensibility, by virtue of which the serous capillaries refuse, or contract against the intromission of red blood, would seem to depend on the regular influx of the nervous influence. That this is the case, appears highly probable, if not certain, from the different results arising from the forci- ble injection of fluids into the arteries of living and dead animals. " Push into the aorta of a living animal, by means of a syringe, different fine fluids, and you will never see them fill the capillary system, or issue by the exhalents;'' when, however, the same experiment is performed on an animal soon after death the fluid will be found to pass readily into the serous capillaries, and pass out by the exhalents, excretory ducts, &c. (Bichat.) Mr. Buniva's experiments quoted by Bichat, with injections upon dead and living animals, illustrate this fact in a very striking manner. He fixed the pipe of a syringe into an artery of a living- animal ; on endeavouring to force the fluid into the vessel he found very ffreat resistance, the piston passing down very slowly, and only with the application of much force. On causing the animal to be suddenly killed, by dividing the spinal marrow just below the occiput, the fluid passed rapidly out of the syringe GENERAL PATHOLOGY OF FEVER. 23 Broussais and his followers are, indeed, fully sensible of the observation of Celsus: Neque quicquam esse stultius quam quale quid vivo homine est, tale existimare esse morienie into jam mor- tuo ; for where they fail in detecting a red and injected state of the mucous membrane of the bowels, they account for its absence by ascribing it to a post-mortem change; thus availing themselves of this fact when it affords an argument in their favour; whilst they manifest an unwillingness to allow any importance to it when it is adduced against their doctrine. It cannot, indeed, be presumed that the injected state of the mu- cous membrane of the intestinal tube, so often discovered in those who die from fevers, is always, or even generally, to be ascribed to a mere post-mortem change; but that such changes do sometimes, nay, often occur, and that they have been assumed as evidences of previous inflammation, there can exist but little doubt. The first obvious effect of the remote febrific causes, consists almost universally in a diminution of the nervous energy, and con- sequently of the action of the heart and arteries. This is manifested by the weak and contracted pulse, the general langour and lassitude, the diminished temperature and the sense of chilliness which usher in all febrile affections. These initial phenomena of fever are espe- cially conspicuous in intermittents, remittents, and in catarrhal affec- tions. There is nothing in the character of these symptoms which can justify the inference that they are dependent on inflammation. "Inflammation," says Dr. Armstrong, "cannot exist in the cold stage of fevers, all the phenomena of which are directly opposed to inflammation." The course and phenomena of intermitting fevers present us, indeed, with insurmountable objections to the "physi- ological doctrine." The periodicity of these fevers is strongly opposed to the idea of their immediate dependence on the gastro-ente- ritis. It is, indeed, true, that affections of an inflammatory charac- ter have been known to recur in a strictly periodical manner; but such cases must be viewed as anomalies, and altogether contrary to the almost universal course and character of phlegmasial diseases. into the artery, although but little force was applied. While the capillaries retained their full portion of vitality, they resisted the introduction of the fluid; but as soon as they had lost their sensibility, in the death of the animal, they yielded like passive tubes to the fluid forced upon them by the vis h, tergo. The application of these facts to the post-mortem production of a red and injected state of the membranous structures, especially the more vascular ones, is easily to be understood. So long as the serous capillaries retain their vitality, they resist the entrance of red blood into them. As soon, however, as their vital pro- perties cease to exist, they lose the power of resisting the intromission of red blood—becoming, in fact, mere passive and yielding tubes. But as the arteries continue to contract on their contents, some hours after the extinction of life, they must necessarily force the blood forward into the relaxed and unresisting capillary system, into which it will therefore be driven, as into a sponge, and give to the more vascular structures, the red and injected state, so often found on post-mortem examination, where no previous inflammation whatever existed. 24 GENERAL PATHOLOGY OF FEVER. An inflammation which observes a perfect periodicity in its atta , must be sui generis. If intermitting fever depend on innammt.athig of the mucous membrane of the alimentary canal, then must i inflammation be periodical, and therefore essentially distinct iron the inflammation which produces remitting fever; tor in malady it must be continuous. These two forms of fever are, now ever, produced by the same remote cause; and we are thereiore forced to admit, by the assumption of this doctrine, that the same remote cause is capable of producing two kinds of inflammation essentially distinct from each other. The character of the remedies, too, which have been found most effectual in arresting intermitting fever, is directly opposed to the idea that gastro-enteritis constitutes its proximate cause. Who can believe that quinine, arsenic, black pepper, and other remedies of a similar character, are peculiarly calculated to cure inflammation of the mucous membrane of the alimentary canal? Indeed, these very articles appear to be par- ticularly dreaded by the disciples of this doctrine, on account of their tendency to create gastro-enteritic irritation, and yet all experience goes to prove that they are decidedly the most prompt and valuable means for the cure of intermitting fever. M. Broussais' theory of the mode in which the remote causes of febrile affections produce gastro-enteritis is gratuitous, and but little calculated to satisfy the understanding. "Every irritation," he says, " which is capable of producing a perception in the brain, passes back by the nerves to be repeated in the mucous mem- branes." Thus, if a person be inoculated with small-pox virus, the irritation of the primary pustule, or of the inoculated point, is con- veyed to the brain, whence it is reflected by the nerves upon the mucous membranes of the alimentary canal, where it establishes an inflammation. This intestinal inflammation constitutes the essential cause of eruptive fever, and the eruption itself is only a metastatic disorder of the cutaneous system. The assumption, then, " that every irritation which is capable of producing a perception in the brain, is reflected by this organ to be repeated in the mucous membranes of the alimentary canal, forms the main principle in the Broussaian doctrine of the etiology of fever. That the mucous membranes of the intestinal tube possess a very wide sphere of sympathetic rela- tions, is a fact indeed as undeniable as it is important in a patholo- gical point of view. But that this structure constitutes a subordinate sensorinm commune, to which all morbific impressions are especially conveyed, after having been perceived by the brain, is a position which all the zeal and ingenuity of its advocates have as yet failed, and I apprehend will ever fail, to place upon that firm basis which it ought to have to serve as a foundation of our pathological faith. I do not mean to object to the general fact, that all impressions capable of ultimately exciting fever, are in the first place communi- cated to the sensorium commune, and thence reflected throughout the system, and sometimes upon some particular organ or structure • but this reflected impression does not, it may be justly maintained necea- GENERAL PATHOLOGY OF FEVER. 25 sarily, establish a focus of irritation, nor always, or even generally, fall especially upon the intestinal mucous membrane. If the impressions of morbific causes are always transferred to the mucous membrane of the alimentary canal, the impressions of all agents, remedial as well as others, must of course be referred to the same structure. This, however, does not accord with the results of observation. When mercury is rubbed on the skin, the salivary glands, the gums, and the mucous membrane of the mouth, receive the chief impressions excited by this agent. Will it be contended that a gastro-enteritis must be established before salivation can be produced? If opium be applied to any part of the body, the im- pressions are concentrated in the nervous centre. When cantharides are applied to the surface, the irritation is conveyed to the neck of the bladder, and not to the mucous membrane of the bowels, and yet fever may be the result. From these and many other similar facts that might be adduced, it is manifest that the supposed law of the animal economy, by which, as is alleged, all febrific impressions are reflected from the brain and repeated in the mucous membranes of the bowels, is gratuitous, or to say the least, highly improbable. The fallacy of those doctrines which confine the primary inflam- mation to some one structure exclusively, is strikingly illustrated by the circumstance, that different writers have fixed on different structures, as the parts primarily affected in fevers. Thus Clutter- buck maintains, with Broussais, that fever is always a purely symp- tomatic affection depending on local inflammation pre-established by the febrific cause. He asserts that this primary inflammation is invariably located in the brain and its membranes, and adduces the phenomena discovered on post-mortem examination, in testimony of the correctness of his doctrine. Broussais, on the other hand, asserts that the primary inflammation is not in the brain, but in the mucous membrane of the bowels, and appeals with equal confidence to the appearances exhibited on dissection for confirmation of his doc- trine. This discrepancy is in itself sufficient to show the weak foundation on which these two doctrines rest; for if the evidence afforded by aulopsic inspection in relation to this subject were not extremely ambiguous, it would, one may suppose, be impossible to draw from it conclusions so very discrepant, and yet so nearly equal in point of plausibility. The advocates of the gastro-enteritic pathology of fever place no inconsiderable reliance for support to their doctrine on, what they are pleased to assert, their superior success in their remediate manage- ment of fevers. Leeches, and an almost total abstinence from food, with cooling, acidulated, mucilaginous drinks, constitute nearly the whole of their remediate applications; and they claim for this mode of treatment, a greater success than that which they allow to others who pursue a more active course of treatment in fevers. It does not appear, however, that the golden age of medical success, so confi- dently promised by Broussais, on the introduction of his doctrine, has 26 GENERAL PATHOLOGY OF FEVER. as yet arrived;* for the statements which have been published in France, in reference to the comparative mortality under the .brous- saian, and the other modes of treatment, give no support to the claims of superior success set up for the former. We might, however, admit the excellence of the Broussaian mode of treating fevers, without yielding our assent to the correctness of the doctrine that the gastro- enteritis is primary where it does exist. There exists but little doubt in my mind, that in continued and remitting fevers, active purgation is not unfrequently carried to an injurious extent; for, although we may, and, as I conceive, ought, to reject the opinion that such fevers depend essentially on the gastro-enteritis, yet we cannot doubt, that a very considerable degree of irritation, amounting in many instances to inflammation, does often supervene during the progress of the dis- ease, as an epiphenomenon, and unconnected with the origination of the fever. In cases where such a condition of the mucous membrane of the intestinal canal occurs, during the course of the disease, the soothing treatment recommended by Broussais, is no doubt more salutary than the vigorous purgative plan so commonly pursued in this country and in England. Unquestionably, intestinal irritation and inflammation perform an important part in febrile diseases. These conditions may arise as consequences of the general febrile reaction, as well as from harsh and repeated purgation, and the use of other irritating remediate agents. But it is equally probable that gastro-enteritis is often excited by acrid and vitiated secretions, and other offensive materials retained in the bowels in consequence of withholding suitable laxatives, in the commencement and during the progress of the malady. Broussais has done much good, by awaken- ing the attention of the profession to these pathological conditions; and thus furnishes another proof of the fact, that new doctrines, though fundamentally erroneous, seldom fail to do some good, by directing the views of physicians to important circumstances, which were previously overlooked, or too much neglected. In leaving this subject, I deem it right to observe, that however widely we may differ from Broussais in relation to the pathology of fever, all must admit that he has just and high claims to the respect and gratitude of the profession for the light which he has thrown on the nature, symptoms and treatment of mucous intestinal inflamma- tion, as well as on the physiological and morbid sympathies of the animal system. Broussais is unquestionably one of the most enlightened and inge- nious pathologists of the present day. His is now the only general * In 1821, Broussais asserted "that the tables of mortality declare in favour of the new doctrine, and that its influence upon population would be more favourable than that of the introduction of vaccinatum." Unfortunately, however, this happy influ- ence of the nouwZfc doctrine, remains yet to be realized ;t and the advocates of the doctrine may console themselves for the tardiness of this influence, with the cer- tain prospect of not being very soon deprived of the opportunity of publishing their ordinary quantum of post-mortem examinations. 3 t Refutation de la Doctrine de M. L. Doct. Broussais. par L. Castel. GENERAL PATHOLOGY OF FEVER. 27 doctrine which especially occupies the attention of the profession. Like all the preceding great doctrines in medicine, it is destined, perhaps, to culminate for a while in the firmament of our science, and to attract its host of worshipers; but, assuredly, sooner or later it must sink again, and add another to the long list of once highly- favoured, but now exploded and neglected doctrines. That the Broussaian system contains much that is valuable, it would be un- just to deny; but to these concessions in its favour, there are, unless the majority of competent judges greatly err, offsets of no small moment. In relation to this doctrine, as indeed to every one else, it behooves us to embrace the useful and reject the false; in short, to adopt the good advice of Lucretius,* 11-----------doctrinam acri Judicio perpende; et si tibi vera videtur Dede manus—aut si falsa est, accingere contra." Having now given a summary of the principal objections which may be urged successfully, I conceive, against the " new physiological doctrine," I proceed to an exposition of the following propositions, as embracing the leading, and it is believed, tenable points of doctrine, in relation to the mode of origin and character of febrile diseases. 1. Fever is a general disease—the sanguiferous system being essen- tially and predominantly disordered. 2. The morbid vascular excitement of fever is located, essentially, in the capillary system of blood-vessels—consisting in irritation, and not in mere increased or decreased action. 3. This irritated excitement may be the result of morbific causes [* Clutterbuck's opinion, published in 1807, gave origin to the doctrine that fever is not a primary affection; but essentially a local inflammation, the seat of which is in the brain. Frank, of Vienna, attributed fever to an inflammation of the arterial system; and some of the Italian physicians extended the same idea to the inner coat of the vena porta. The advocates of the non-essential doctrine of fever, however, have chiefly proceeded on the foundation of Broussais. As often as they have been able to detect any trace of morbid alteration of structure in the intestinal canal, after the termination of a fever, they have attributed the general disorder to a local cause. It had long been known that the glands of Peyer and Brunner, in the mucous coat of the small intestines, were liable to inflammation and even ulceration. But it was reserved for the celebrated Louis, of the Hotel Dieu, in Paris, to discover that such a condition of these small glandular follicles, espe- cially the conglomerate ones, was the true cause of one of the most frequent forms of fever. The progress of pathological anatomy has unquestionably developed new and important facts; but we may doubt whether it has not of late given a wrong direction to medical inquiry. Effects and concomitant phenomena are perpetually mistaken for causes. It would not surprise us if some writer should come out with the doctrine that cutaneous eruptions and scabs, and that buboes and carbuncles, are the true causes of the small-pox and plague.—Ma] 28 GENERAL PATHOLOGY OF FEVER. acting directly on the internal surface of the sanguiferous syste™'em» of irritating impressions conveyed sympathetically to this sy , from a primary focus of irritation. ■ ih 4. The first link in the chain of morbid actions, which occur in me development of fever, always commences in the nerves. 5. The remote or exciting causes of fever rarely produce local inflammation, anterior to the development of the general iebriie reac- tion. Their action is confined to the production of morbid impres- sions on the nerves, which, passing inwards to the brain, usually cause a temporary depression of its energies, and consequent disturbance in the equilibrium of the nervous and vascular excitements; at the same time that the morbid impressions reflected by the brain through- out the system, contribute to the functional disturbance and irritation of certain internal organs or structures. 6. Although local inflammation is not essential to the production and support of fever, yet, in many instances of idiopathic or general fever, more or less inflammation supervenes, after the febrile reaction is established; and occasionally the development of the febrile excite- ment and local inflammation is effected simultaneously. 7. Inequilibrium of excitement, and local determinations of blood, constitute an important characteristic of fever; for, although strictly a general malady, there are always some organs or structures in a state of increased morbid excitement, whilst, at the same time, others are in an enfeebled, languid or torpid condition. In stating that fever is a general malady, it is not presumed that every structure of the organization is in a state of actual disease; but as the nervous and vascular systems are so intimately concerned both in the composition and functions of every part of the body, it may well be inferred, that where these two systems are in a morbid con- dition, as they manifestly are in fever, every other irritable and sensible structure must suffer more or less functional derangement. Never- theless, it cannot be questioned that the essential morbid excitement, which constitutes fever, is located in the sanguiferous system. The disordered action of the heart and arteries—the increased temperature of the body—the altered state of the secretions—the morbid appear- ances on dissection—and, in most instances, the changed state of the blood, afford sufficient evidence of the paramount disorder of the blood-vessels in febrile affections. The morbid vascular action of fever is an irritated and not a mere increased action of the heart, arteries and capillaries. There exists a wide difference between irritation and mere excitation. The for- mer is the result of stimuli acting either directly or indirectly upon an organ or structure, whose vital properties are in a deranged or mor- bid condition; and is therefore always essentially connected with a disordered state of the nerves of the part affected. This result is not simply a greater or less degree of the natural or healthy excitement, but an action or excitement essentially morbid or distinct from healthy action. Mere excitation, or increased action, on the other hand is the result of stimuli acting on an organ or system whose vital pro- perties remain in a healthy or underanged condition. A few ounces GENERAL PATHOLOGY OF FEVER. 29 of alcohol, for instance, will cause a high degree of arterial action in an individual not accustomed to this stimulus; and the same effect will be produced by any sudden and violent bodily exertion, as run- ning, rapid walking, &c. Here, then, there is increased action of the heart and arteries, with an augmented state of the animal tempera- ture ; but this does not constitute fever. The vital properties remain in their normal condition, and the organs thus inordinately excited, return to their natural and healthy grade of action, as soon as the ex- citing cause ceases to act. As, however, all excessive action tends to weaken, and finally to derange the vital properties of the over-excited parts, so, when such stimuli are very protracted in their influence, they may, at last, disorder these properties and give rise to fever. Without such a derangement or morbid condition of the sensibility and irritability of the heart, arteries and capillaries, no fever can occur; for so long as the vital properties are in their natural state, all irritants or stimuli can produce only a greater or less degree of nor- mal excitement, and the secretions will be diminished or increased, but not depraved. As soon, however, as these properties have de- parted from their healthy condition, every stimulus, whether natural or morbific, must necessarily excite morbid actions. Hence, it may be concluded that every cause which produces fever, in whatever way its influence may be conveyed to the sanguiferous system, must necessarily derange its vital properties, either directly or indirectly, before that general irritated vascular action which constitutes fever, can be established. It is evident, therefore, that although the characteristic pheno- mena of fever depend on morbid action of the heart, arteries and capillary vessels, the nerves also are essentially and primarily disor- dered in febrile diseases; for irritation, as has just been observed, necessarily implies a morbid or deranged condition of the vital pro- perties, and it cannot be doubted that, so far, at least, as the capillary system is concerned, these properties are derived immediately from the nerves. From a careful analysis of the phenomena of fever, it would ap- pear that, although the sanguiferous system, generally, is prominently disordered in fever, yet the essential febrile excitement is especially located in the capillary system of blood-vessels. Fever cannot exist without capillary irritation or derangement of the secretory and ex- cretory functions. So long as the capillary functions remain free from morbid excitement, or the principal secretions continue to be per- formed in a healthy manner, no increased action of the heart and arteries can constitute fever, but only an over-excited state of these organs, which will subside when the exciting cause is removed. A person who is thrown into a violent gust of passion, experiences vehement action of the heart and arteries; but unless the capillary vessels are brought into a state of morbid excitement, or irritation, it will not be fever, but simple super-excitation.* On the other hand, * Some of the sentiments stated in this chapter, do not differ materially from those given by Dr. Southwood Smith, in his interesting work on fever. The views 30 GENERAL PATHOLOGY OF FEVER. manifest disorder in the action of the heart and arteries, d ^^ appear to be essential to the existence of fever. Fevers o f malignant and fatal character-attended with unequivocal man ie. a- tions of capillary disorder, such as hemorrhage, P**?0^83 * " r' flammation; not (infrequently occur, in which no obvious; deuaturn from the natural action of the heart and arteries can be oetmeo. Dr. Smith, in his very valuable treatise on fever, observes that; tne order in which the morbid actions which constitute fever, occur, « is, first, derangement in the nervous and sensorial functions ; tn s is the invariable antecedent; secondly, derangement in the circulat- ing function ; this is the invariable sequent: and thirdly, derangement in the secreting and excreting functions : this is the last result in the succession of morbid changes. Derangement in the junctions ot secretion and excretion never comes first in the series : derangement in the nervous and sensorial functions never comes last in the series: derangement in the function of the circulation never comes either first or last in the series, but always the second in succession." That derangement of the nervous system constitutes the initial link in the chain of morbid actions which occur in the development of fever, cannot be doubted. The mental and muscular languor—the general malaise and uncomfortable sensations—the pains in the loins and extremities—the morbid sensibility to low temperature—the dejection and irritableness of temper, and the confusion and weak- ness of the intellectual powers, which so universally usher in febrile diseases, afford unequivocal evidence of pervading derangement in the nervous system. In relation to the subsequent order of the morbid changes which supervene in the development of fever, however, we cannot adopt the sentiments expressed by Dr. Smith. The assertion, that the heart and arteries are universally and necessarily deranged, next in order to the primary disorder of the nervous system, and before the capil- lary or secretory extremities of the blood-vessels are brought into a state of morbid excitement, appears, I think, contrary both to correct physiological principles, and to the results of observation. It is well known that the extreme vessels, the secreting capillaries, are incom- parably more closely connected with, and dependent for their func- tions on, the nervous system, than the heart and larger blood-vessels. It is scarcely necessary to refer to the experiments of Wilson Philip and other modern physiologists in support of this observation. From this physiological principle alone, then, we would be led to infer, that the extreme vessels—those which are immediately, or at least very intimately, concerned in the process of secretion and calorification- would be the first to suffer derangement of function from general morbid excitement of the nervous system. That capillary derange- ment is, in fact, the immediate sequent of the primary functional disturbance of the nervous system in the evolution of fever, appears to me sufficiently demonstrated by the phenomena presented in the here given, whether correct or incorrect, I have taught in my public lectures for seven years past. GENERAL PATHOLOGY OF FEVER. 31 forming stage of the disease. Who does not know that torpor of the cutaneous exhalents is one of the most common initial symptoms of fever ? This function is frequently prominently deranged, before any manifestations of the morbid action of the heart and arteries can be detected. When kiono-miasmata acts slowly upon the system, we often find, along with the above-named symptoms indicative of dis- ordered nervous excitement, decided evidence of functional derange- ment of the liver, as well as of the perspiratory vessels. The utter groundlessness of Dr. Smith's sentiments on this point, may, indeed, be predicated on the simple circumstance, that it has led him, neces- sarily, to deny, that pneumonia, hepatitis—in short, all the affections embraced under the general term phlegmasia, are fevers ! Believ- ing, as he does, that the order of morbid changes, from the nerves to the heart and arteries, and finally, to the secretory capillaries, is uni- versal, and as invariable as the laws of nature, he is, of course, obliged to deny the name of fever to the general sympathetic pheno- mena which occur in consequence of local inflammation—for in these symptomatic fevers the successive morbid changes occur, he says, in a different order. " Febrile diseases," he observes, " are commonly divided into idiopathic and symptomatic—a division which is liable to the fundamental objection, that the diseases included under the second head are not fevers, but inflammations. There are no fevers, but idiopathic fevers." And the reason why the general symptoms of the phlegmasia do not constitute fever is, he says, because " in pneumonia, in enteritis, in hepatitis, &c, the spinal cord and the brain are never the organs in which the first indications of disease appear; the earliest indications of disease that can be discovered, having their seat in the affected organ itself, and it being only after the disease has made some progress, that the other organs (the heart and arteries, and the brain) and functions are involved." Ingeniously as Dr. Smith has argued upon this subject, very few, it may be presumed, will agree with him in denying, that the general morbid actions arising from local inflammation, are truly and essentially febrile. In truth, however, the alleged diversity in the order of the morbid changes of idiopathic and symptomatic fevers, has no existence. Local inflammation, like every other exciting cause of fever, that does not act directly on the heart and arteries, can affect the general system only through the medium of the nerves; and hence, we almost invariably find the same train of symptoms accompanying the rise of fever from inflammation, as is known to usher in idiopathic fever. What do we observe when fever comes on from a wound ? The patient, at first, experiences some degree of febrile languor— accompanied with a sense of slight chilliness, malaise; and derange- ment of the exhalent functions of the skin. These symptoms, though often so slight and transient as to be scarcely perceptible, invariably precede the occurrence of the febrile reaction of the heart and arte- ries ; and hence the order of sequence in the morbid actions, which take place in the development of symptomatic fever, does not differ from that which obtains in idiopathic fever. The nerves always receive the first shock and morbid change. This speedily gives rise to 32 GENERAL PATHOLOGY OF FEVER. more or less conspicuously deranged action of the secretory capilla- ries—and finally the heart and arteries are morbidly excited. While Dr. Smith, more confidently than prudently asserts, that " there can be no fever but idiopathic fevers," Broussais and his dis- ciples assert, that " the existence of idiopathic fever is impossible. ' Such are the contradictory extremes to which theory is apt to lead the understanding! That fever may occur both with and without local inflammation, may be disputed by theorists, but cannot be doubted by those who observe diseases with unbiased judgments, in the light of common sense. It must, indeed, be admitted, that local irritation or local morbid action invariably occurs, as the initial morbid condition, whence the series of consecutive deranged actions in the evolution of fever have their origin. This admission does not imply a concession in favour of the Broussaian doctrine, since it is predicated, in part, on the demonstrable position that the local morbid excitement is not unfre- quently located in a greater or less extent of the lining membrane of the blood-vessels themselves, and produced by irritating agents admit- ted into the circulation from without, or by retained recrementitious elements acting directly on the internal surface of the sanguiferous system.* It appears to me that there is no pathological fact which is more susceptible of satisfactory illustration, than that fever fre- quently arises from morbific causes acting immediately on the san- guiferous system, and establishing a primary irritation in a greater or less extent of its internal lining membrane. Without denying the all-pervading influence of that principle of the living system, called sympathy—or still more comprehensively, without denying that all the phenomena of life, whether of health or disease, are but so many manifestations of the action of the living solids, it is a truth equally undeniable, that the blood may and does frequently serve as the medium through which deleterious agents act immediately on the heart and arteries, and thus give rise to febrile phenomena. " The venous system," says Bichat," may be regarded as a general reservoir, into which are poured all the materials which are to be thrown out of the body, and ail those which are to enter it. In this last respect, this system of vessels performs an essential part in the production and support of diseases. The deleterious sub- stances may be introduced into the blood-vessels with chyle, and produce ravages in the system in circulating with the fluids. There can be no doubt, moreover, that, besides the principles which convert the venous into arterial blood, there often passes through the lungs into the circulation, deleterious miasmata, which produce diseases, as my experiments on asphyxia have proved. The intestines, the lungs, and the skin are the three avenues through which the morbific agents may gain admission into the circulation."? That foreign substances are readily taken up by the absorbents * M Bouillaud, whose work I have already mentioned, advocates this view of tne etiology of certain varieties of fever. t Anatom. Gener., vol. i. p. 284. GENERAL PATHOLOGY OF FEVER. 33 and veins, and conveyed into the circulation in an unassimilated state, is now no longer a subject of doubt or dispute. It appears to me highly probable, that miasmatic agents act upon the animal system, in part at least, by being admitted through the lungs, into the current of the circulation. Some contend that these aerial morbific causes act primarily on the stomach. It is asserted, that the miasma, becoming entangled in the saliva, and swallowed with this fluid into the stomach, establishes a primary morbid impression in its delicate mucous membrane. It is alleged, in confirmation of this opinion, that the stomach, possessing a very extensive circle of sympathetic relations, and being highly sensitive to impressions, is peculiarly calculated to become the primary focus of morbid excitement, from external morbific causes. It is affirmed, moreover, that the initial symptoms of fever point out the primary influence of the febrific cause on the stomach. The depressed or abolished appetite, the nau- sea and vomiting, and the peculiar sense of uneasiness in the epigas- trium, are considered as affording strong evidence of the correctness of this opinion. It is asserted, finally, that the lungs are endowed with an inferior degree of sensibility, and that their sympathetic relations are by no means very extensive, and that, therefore, they are but imperfectly adapted for receiving and propagating morbid impressions from external causes. In reply to these arguments, it must be observed, that it does not seem probable that a sufficient quantity of miasmata could gain ad* mission into the stomach to produce disease. As to the evidence drawn from the character of the premonitory symptoms, it cannot afford any available support to this doctrine. A severe wound, or contusion, will give rise to nausea, vomiting, and immediate loss of appetite. Such phenomena only show that the stomach readily sympathizes with impressions made on every part of the body, when of sufficient degree of intensity. With regard to the alleged insen- sibility of the lungs, or their limited sphere of sympathy, we might admit its justness without being reduced to the necessity of adopting the opinion that miasmata act primarily on the stomach. It is not presumed that aerial morbific agents act simply on the nervous ex- tremities of the respiratory passages, and thus give rise to a chain of sympathetic morbid actions. It is contended, that agents of this kind pass through the lungs into the current of the circulation, or effect certain morbid alterations of the blood, in consequence of which, the lining membrane of the heart, arteries, and capillary sys- tem is irritated, and the vascular system thrown into a state of febrile excitement. That agents of this kind are absorbed into the circulation, and act upon the system through the medium of the blood, may be inferred from a number of familiar facts in relation to the inhalation of odoriferous effluvia. The inhalation of the fumes of turpentine, of garlic, and of various other substances of a similar character, is speedily followed by the manifestation of these odours in the urine. How are we to account for the extraordinary effects which arise from the inhalation of nitrous oxide, and of the vapour of sulphuric ether ? It does not seem probable that these effects are vol. i.—3 34 GENERAL PATHOLOGY OF FEVER. produced by the mere action of these causes on the puli < Y nerves; for when these substances are taken into the stomac. , nerves of which are so highly sensitive, no such c°?se*UGJ£*,in still more frequently the result of a purely sympathetic \uvai 1011 proceeding from local irritation or inflammation pre-estabhsned Dy the febrific cause. This latter mode of febrile origin is accordmg to some modern pathologists, the only possible way in which levers can arise ; as if morbific impressions made directly upon the blood- vessels, could be less apt to derange their functions than when com- municated to them sympathetically through the medium ot the nerves. It is probable, however, that the primary morbid condi- tion whence the sympathetic febrile actions emanate, consists much more frequently in mere irritation of functional derangement than in actual inflammation. I presume that those febrific causes which do not make their impressions directly on the lining membrane of the heart, arteries, or capillaries, by being admitted into the circula- tion, cause, in the first place, irritation and consequent functional derangement in one or more important organs or structures of the system. In consequence of this local irritation or deranged action, the equilibrium of excitement and of the circulation becomes dis- turbed, the vital properties deranged, and the sanguiferous system is finally brought into a state of febrile reaction. Fever, as has already been observed, always, perhaps, commences by a local irritation, or morbid excitement. Even when the disease results from causes that act immediately on the internal surface of the vascular system, the irritation, or primary morbid excitement, is probably confined, at first, to a comparatively small portion of this system. Every agent, whether morbific or medicinal, appears to have a tendency, in its ulterior operation, to affect particular organs or structures in preference to others. On whatever part of the sys- tem the primary impression is made, the excitement produced is chiefly conveyed to some particular organ or part, according to the peculiar character of the primary impression. Ergot, whether re- ceived into the stomach, or injected into the rectum, produces an excitement in the nerves of the part to which it is applied, which is especially conveyed to the gravid uterus, and so far as can be per- ceived, to no other part. The infusion of jalap, introduced into the circulation, will act upon the alimentary canal, and produce purg- ing : cantharides, whether taken into the stomach or applied to the Of late an attempt has been made to revive the humoral pathology, by a more accurate chemical examination of the blood, and by experiments of injecting morbid and irritating matters into the circulation. The facts which have been ascer- tained certainly show that a morbid state of the blood may perform an important part in developing some of the phenomena of fever. But they do not warrant the conclusion of some of the European investigators, nor of Dr. Stevens of the West Indies, that fever is entirely dependent upon such a cause. The saline treatment of Dr. Stevens has not as yet got into credit with the profession; nor has the prac- tice of medicine been at all modified by the recent advance of humoral patho- logy.—Mc] v GENERAL PATHOLOGY OF FEVER. 37 surface, is apt to inflame the neck of the bladder ; and, in short, the influence of almost every agent appears to possess a kind of elective affinity for some particular organ or structure of the organization. That this should be the case, might, indeed, be inferred from physio- logical principles, independent of the evidence of experience. That each organ and structure of the animal system is endowed with a peculiar modification of the vital properties, may be regarded as an established fact in physiology. In this principle we may perceive the reason why different agents manifest peculiar tendencies to act on different parts of the system. Without doubt when an impres- sion is made on the system, it will be most felt by that structure whose specific or peculiar vital properties are most in relation with it. When an impression is made on the nervous extremities of any part of the body, the excitement produced is conveyed by the nerves to the brain, and from this organ it is reflected or radiated through- out the whole nervous system. That this is the ordinary course of nervous excitement from impressions made on the sentient extremi- ties, will scarcely be disputed by any one who has carefully attended to the functions of the brain and its appendages. It is impossible to give a rational explanation of many sympathetic phenomena, unless we trace the course of nervous excitement from its origin to the brain, and thence to the part which manifests the sympathetic ac- tion. If, then, each organ and structure of the animal system be endowed with its peculiar modification of excitability* we may justly presume, that some parts of the organization will be insensi- ble, whilst others will be more or less sensible to particular impres- sions, and consequently there will be some parts in which a new excitement will be produced by the impressions reflected by the sensorium commune, whilst, in other organs and structures no im- mediate effect will be produced. Thus, if tartar emetic be kept in contact with the external region of the stomach, the impression which it causes will be conveyed to the brain, which in its turn will reflect the impression throughout the whole nervous system; but as the stomach alone is endowed with a mode of feeling capable of receiving this peculiar impression to a prominent degree, it will be in this organ that its effects will be most conspicuous.! * The word excitability is here used to express the power of being excited into action, and includes both sensibility and contractility. f The author of a Review of the first edition of this work, doubts the correct- ness of this assertion. It must be admitted, that tartar emetic, when applied to the external surface, very rarely produces either nausea or vomiting. I have, nevertheless, met with one remarkable instance of this kind. At three different periods a solution of this article was applied to the epigastrium, and at each time he experienced very distressing and protracted nausea. The general fact, however, which it is intended to illustrate by the above observation, cannot be disputed. It is well known, as has been observed in the preceding page, that to whatever part remedial substances are applied, they manifest the same ten- dency to act on particular organs or structures, as if they were taken into the stomach. I have known tobacco applied to the feet to give rise to nausea and 38 GENERAL PATHOLOGY OF FEVER. Let us suppose, then, that a febrific agent acts primarily upon the nerves of the stomach or of the skin, or of any other part oi the body. The impression produced, will be conveyed to the senso- rium commune, whence it will be reflected throughout the whole nervous system. But as the various organs and structures ot the system are endowed, each with its own peculiar modification ol the vital properties, some may be insensible, whilst others, perhaps, are peculiarly susceptible of receiving and responding to the re- flected morbific impression; and these, it may be reasonably pre- sumed, Vvill be irritated and functionally deranged, before the other organs or structures become affected. From the part thus primarily irritated, the morbid excitement passes from organ to organ, or tissue to tissue, according to their various sympathetic relations with each other, and with the part primarily affected, until the whole system becomes morbidly excited. It is extremely improbable that the morbid excitement or impres- sion caused by a febrific agent, can ever bring every part of the system, simultaneously, or pari passu, into a state of morbid action. The direct influence of the remote or exciting causes of fever, do not, probably, extend beyond the simple impression which they make on the sentient extremities. Every subsequent morbid change in the development of fever, must depend wholly on the relative affinities of the various structures with each other, and with the cha- racter of the primary impression; and, from what has been said above, it can scarcely be doubted, that the primary impression or nervous derangement, resulting directly from the action of the mor- bific cause, always terminates in the production of prominent mor- bid excitement in some particular organ or structure, preliminary to the actual development of the general febrile vascular reaction. That the primary morbific impressions are, however, almost uni- versally directed upon the mucous membrane of the alimentary canal, as is asserted by Broussais, appears to be as far from truth, as that all fevers are purely symptomatic. Almost every organ or structure of the system may, without doubt, be the first to suffer functional derangement or irritation from external morbific im- pressions. The lungs, the liver, the brain, or the skin, &c, some- times receive the reflected impressions, and become the primary focus whence the febrile actions emanate. Observation, moreover, discountenances the opinion that the primary local derangement thus produced, amounts often to the grade of inflammation. De- ranged or irritated excitement of an organ or structure, may be ade- quate to set on foot a train of morbid changes which will ultimately terminate in febrile reaction. A draught of cold water, while the body is in a state of free perspiration, may, in its ultimate conse- quences, establish fever. In this case the impressions of the cold water on the nerves of the stomach, are transmitted through the vomiting, and every physician must have observed similar facts. [I have repeat- edly observed this fact, tartar emetic plasters occasionally produce severe vomitin<* in irritable patients.—Mc] GENERAL PATHOLOGY OF FEVER. 39 medium of the sensorium commune, to the cutaneous exhalents and capillaries. A state of torpor and functional derangement of these vessels, together with the deranged sensibility of the cutaneous nerves, immediately ensues, and the patient experiences a sense of chilliness, with more or less constriction of the extreme vessels. These, then, are the first sympathetic phenomena arising from the influence of the remote or exciting cause; and from these morbid changes, others proceed in regular sequence until the fever is fully developed. Thus, from the torpor of the exhalents and diminished circulation in the external capillaries, three pathological conditions necessarily arise, which tend especially to excite febrile reaction. In the first place, a large portion of recrementitious perspirable mat- ter will be retained in the circulation; secondly, the retreat of the blood from the extreme vessels will cause it to accumulate in the heart and large internal vessels; and thirdly, the action of the liver* and other internal organs, will be more deranged in consequence of their direct sympathetic relations with the cutaneous exhalents. But although the organs which sustain the primary irritation— and from which the morbid febrile changes are diffused throughout the system, as from a centre, are not, perhaps, at first in a state of actual inflammation, yet, as they are already morbidly irritable and irritated, they will be especially apt to pass into a state of complete inflammation soon after the febrile reaction is established, and an increased momentum given to the blood. It may be observed, too, that when a morbific cause acts directly on the stomach, as in the example just assumed, the fever will be apt to become early com- plicated with conspicuous irritation or inflammation of the mucous membrane of this organ ; in consequence of having sustained the direct injurious impressions of the remote cause, and consequently, being, from the very onset of the disease, in a morbid condition. It must be remembered that inflammation consists not only in congestion of the inflamed capillaries, but also in an altered or mor- bid condition of their vital properties: and hence, when an organ is already in a state of morbid excitement or irritation, inflammation will very readily ensue, when, by a general increased momentum of the circulation, the blood is urged into the debilitated and morbid capillaries. It is on this account that we so often find inflammation supervening in the stomach and intestinal canal in fevers. The mucous membrane of these organs being so much exposed to the action of irritating causes, is far more frequently the seat of irrita- tion than any other structure of the system, and it is almost invari- ably in a more or less deranged condition in all general diseases. This being the case, it is evident that this structure must be especially liable to secondary inflammation in febrile affections ; and this, in fact, is fully confirmed by experience. Inequilibrium of the circulation and excitement, is one of the * Vide Johnson on the Diseases of Tropical Climates. Of the correctness of his sentiments, concerning the influence of what he calls the cutaneo-hepatic sympathy, I entertain no doubt. 40 GENERAL PATHOLOGY OF FEVER. most important characteristics of fever. Although fever is emph.- ticallv a general malady, and a morbidly excited condition, it musi not be supposed, that every sensible and irritable structure, tn9usn functionallv deranged, is in a state of increased excitement, wmte the heart and arteries are energetic, and morbidly active, the mus- cular system is usually languid and enfeebled. An increased ac- tivity of the intestinal capillaries and exhalents may be attended with diminished activity of the capillaries and exhalents ot the external surface. Inordinate action of the kidneys is often accom- panied with torpor of the liver, and always with torpor ol the cutaneous exhalents. Sometimes the capillary system is inordi- nately active, whilst the heart and arteries manifest but little or no increase of excitement; and occasionally the brain and nerves are in a state of great activity, with very feeble reaction of the heart and arteries. The same observations apply to the distribution of the blood. Whilst it is morbidly deficient in some organs, it will be excessively abundant in others; whilst the capillaries of one struc- ture or organ are engorged and inflamed, those of other parts will be devoid of the regular portion of the circulating fluid. These facts have a most important bearing on practice; for they point directly to the fundamental principle of treatment—namely, to excite and invigorate those organs that are torpid, at the same time that we depress and debilitate those that are morbidly active. It has been supposed that febrile excitement, or the essential mor- bid action of fever, is always the same ; and that the various modi- fications which this form of disease is known to assume, depend wholly upon the local irritation or inflammation which may occur, or rather the organ or structure which may be its seat. To a certain extent, this opinion appears to be well founded. It is very evident, for instance, that in proportion as the brain and nerves become affected, so will the fever acquire a low or typhoid grade in its general character. Of two individuals seized with fever from the influence of atmospheric vicissitude, one will, perhaps, be affected with a low or typhoid form of fever, whilst, in the other, the fever will assume a high grade of inflammatory or synochal reaction. In the former, prominent symptoms of severe nervous disorder will attend; and if the disease be violent, decided manifestations of cerebral inflam- mation will probably occur. In the latter case, little or no prominent signs of cerebral disturbance or irritation will ensue; but instead of this, symptoms of local inflammation in the fibrous or serous struc- tures, or in one or more of the abdominal organs, will probably be observed. ' That the occurrence of irritation or inflammation of the brain should impart a low and typhoid character to fever, and thus give to it a peculiar aspect, is by no means difficult to comprehend ; for it is manifest, that when the fountain of the vital energies the b'rain is prominently deranged, all the powers of life, however excited' must languish and sink. This subject will, however, be more par- ticularly discussed under the head of continued fever, being referred to at present merely for the purpose of directing the reader's attention GENERAL PATHOLOGY OF FEVER. 41 to the general fact, that fevers, arising from the same cause, and essentially identical, receive important modifications from the seat and grade of the local affections which may supervene. The mode in which the occurrence of local inflammation may be favoured during the progress of fever, has already been mentioned. Besides the peculiar influence of the remote causes, in deranging particular organs or structures, in preference to others, and thus laying the foundation for local inflammation, there are, however, other cir- cumstances which are, perhaps, still more commonly concerned in favouring the supervention of inflammation, and inviting it to par- ticular organs. The human system is rarely found in so perfect a state of health, as that some of its various organs or structures are not more or less debilitated or disturbed. The multifarious influ- ences that are continually operating on the animal economy, do not suffer the vital machine to go on without some, though often imper- ceptible, derangement in one or more of its various organs. Add to this, the congenital debility of some structures, and the constitutional prepotency of others, and we have a sufficient number of latent causes, (varying in different individuals, and in relation to some, in the same individuals at different periods,) to determine the occurrence of local inflammation, when the nervous and vascular systems are thrown into a state of tumultuous excitement. Much variation occurs in different cases, as to the period after the commencement of the febrile changes, when local inflammations of this kind supervene. If any organ or structure happen to be espe- cially predisposed to inflammatory excitement, or when the exciting cause is of such a nature as to act with great force upon some organ or structure, inflammation may commence with the onset of the febrile vascular reaction. More commonly, however, the local inflammation does not supervene until several days after the com- mencement of the fever; and in many instances, not until the latter period of the disease. The occurrence of local inflammation in general fevers, of course, always greatly increases the obstinacy and danger of the disease ; and this is pre-eminently the case, when such inflam- mations supervene in fevers of typhoid character. Prone, as febrile affections unquestionably are, to give rise to secondary inflammations, many instances occur which remain en- tirely free from inflammation throughout the whole course of the malady, although irregular determinations and inequilibrium of excitement appear to be inseparably connected with this form of general disease. It has been observed above, that fevers, essentially identical in the nature of the general febrile excitement, often assume prominent modifications, apparently radically diverse from each other, in con- sequence, solely, of the different organs or structures which happen to sustain the principal force of the malady. From this unquestionable fact some pathologists have inferred that there can be fundamental and specific diversities of fever, presuming that the general febrile excitement is always essentially the same ; and that all the diversities which occur in the course and phenomena of this mode of disease, 42 GENERAL PATHOLOGY OF FEVER. are invariably the result of the diverse local affections that may accompany the malady. It appears to me, however, that the °c™r- rence of original and specific diversities in the nature ot leD™e excitement, is susceptible of very plausible, and, to me at least, sutn- ciently satisfactory illustration. It is impossible to conceive why the capillary system of blood-vessels, in which doubtless all the essential febrile actions reside, should not be as susceptible of radical diversities of excitement as the nervous system itself. Upon this point we may be allowed to refer to the exanthematous affections; for, whatever Broussais and his followers may say to the contrary, some of these diseases are, at least in the first stage, simply febrile, without local inflammation. In the general phenomena of the fever of distinct small-pox, during the first day of its course, there is nothing that is different from an ordinary synochus, and yet no one can for a moment seriously doubt, that the essential morbid excitement of the extreme vessels in this affection, is specifically distinct from that of all other febrile diseases. It is true that this disease is produced by a specific cause ; but the morbific impressions made by malaria, are probably as distinct from those of cold, as the impressions of small- pox virus are from those of either of them. No one has ever observed yellow fever or the plague to arise from atmospheric vicissitudes; and malaria by itself has, I presume, never been known to give rise to inflammatory rheumatism, or to simple catarrhal fever. If, then, in relation to the exanthemata, general febrile excitement is unques- tionably susceptible of radical and specific peculiarities, the possi- bility of such fundamental diversities, in the nature of the morbid excitement of fever, independent of accidental local affections, must be admitted, even in the general fevers, usually denominated idio- pathic. It is probable, that koino-miasmata, idio-miasmata, and cold, or atmospheric vicissitudes, produce each its peculiar mode of morbid excitement; for, although the general and obvious febrile actions, and even the accompanying local affections which they respectively produce, may not be perceptibly diverse, yet, it may be presumed, the fundamental morbid condition or excitement of the nervous and capillary systems, upon which the febrile phenomena depend, is in each variety of fever, radically distinct, or sui generis. So far, however, as the fevers occasioned by one or the other of these remote cases, differ in form and general character from each other— as, for instance, the various forms of miasmal fevers—it can scarcely be doubted, that the most common source of these diversities consists in the accidental local affections which occur, or the character of the structure most prominently deranged, or the greater or less intensity of the operation of the remote cause. CAUSES OF FEVER. 43 CHAPTER II. OF THE CAUSES OF FEVER. The causes of fever are generally divided by pathologists into two varieties, the predisposing and the exciting. The former are all those external and internal causes which tend to lessen the power of vital resistance to the influence of morbific agents. The latter are those causes which excite actual disease by the deleterious or irritating impressions which they make on the animal system. There exists, however, no absolute difference in the nature or character of these two varieties of morbific causes. The same agent, or circumstance, may manifest its influence on the animal economy, either as a pre- disposing or an exciting cause of fever, according to the degree of intensity with which it acts, or the previous condition of the system. Sect. I. Of Predisposition, and Predisposing Causes. When, either from a general condition of the organization, or some local, functional or organic defect, the animal economy is especially susceptible of the influence of morbific causes, a predisposition to disease is said to exist; and this predisposing condition may be either natural, or accidental, or hereditary. As the human system is continually under the influence of causes which have a tendency to interrupt and terminate its actions, life would be but ephemeral in its duration, and harassed by constant disease, if the animal organization were not endowed with the inhe- rent power of resisting, to a degree, the influence of injurious causes. It is by the aid of this vital resistance, that man is enabled to live through a long series of years, amidst a multiplicity of causes, which conspire unceasingly to his destruction. In relation to the degree in which this power of resisting injurious influences is possessed by dif- ferent individuals, there exists great diversity : and hence the various degrees of constitutional or natural predisposition to fever, which ob- tain among different individuals. Thus, the prick of a needle will, in one individual, cause great pain and constitutional irritation; in another, syncope ; in a third, convulsions or tetanus ; and in a fourth, scarcely any perceptible consequences at all.* There exists, there- fore, a natural or constitutional predisposition to disease in some individuals, wholly independent of accidental causes or mere casual debility ; and this constitutional aptitude to disease depends, proba- bly, on the peculiar organization of the animal system. Under the head of natural, or constitutional predispositions, must be ranked those specific predispositions which render the system susceptible of certain specific diseases, and which are wholly lost by * Sur le differens de Degrees de Resistance vitale dans les Maladies, &c. Par M. L. Martinet, M.D.—Revue Medkale, Oct. 1824. 44 CAUSES OF FEVER. the actual occurrence of these maladies. These specific Pl^po- sitions are especially incomprehensible and mysterious. temperament, nor constitutional vigour, nor debility, nor y - cumstance connected with the health of the individual, appears 10 have any relation with, or influence upon them. With regard to accidental, or acquired predisposition, observa- tion has not left us so entirely in the dark. According to the late Dr. Rush, general or local debility, accompanied by an increased excitabilitv, constitutes the state of predisposition to lever, vvitnout doubt, general debility, with increased excitability, must render the system more liable to the action of irritating or exciting causes; yet it does not appear that this condition of the system can, with pro- priety, be considered as constituting the essential state of the organi- zation which predisposes to fever. It is well known that the most robust and healthy individuals are generally the first and most certain victims of febrile epidemics. The vigorous and healthy are often prostrated under the devastating dominion of pestilence, and even under the less ruthless sway of the milder paludal fevers, whilst the feeble and the valetudinarian pass along untouched. It may, more- over, be observed, that in the feebleness of convalescence from bilious, typhus, and other forms of fever, fresh attacks, or relapses, are by no means so common as one would expect, if mere debility constituted febrile predisposition. When we wish to obviate fever, after a sur- gical operation, we reduce the system by a low diet, purgation, and perhaps blood-letting.* In a general way, every cause, capable of deranging the health of the animal economy, may, when acting with moderate force, produce such a change in one or more organs, as will predispose the system to fever, requiring only some further exciting cause to evolve actual febrile disease. Predisposition, produced by the influence of acci- dental causes, consists, probably, always in more or less functional derangement of one, or, at most, a few structures or organs, or in a disturbance of the healthy balance of excitement and the circulation. I have already stated some reasons which render it highly probable that the impressions of every morbific cause, on whatever part of the system primarily made, is, in the first place, reflected upon some par- ticular organ, according to the nature of the impression, and the organic sensibility of the various parts of the system. If this be cor- rect, it is manifest, that if the morbific impression, thus reflected upon an organ or structure, be too weak to establish a sufficient degree of irritation to excite general derangement, or febrile reaction, the result will be only a slight degree of insulated functional derangement, or irritation, which, though not manifested by any feelings or appear- ances of ill health, is still an incipient link of disease, and wants only some additional morbific influences to enable it to put in motion the latent train of morbid sympathies. How greatly mere functional derangement of an important organ aids the cause of fever in deve- loping diseases, is often conspicuously illustrated by the influence of * Richter's Specielle Therapie, vol. i. p. 36. CAUSES OF FEVER. 45 digestive derangement in the production of fever. Let but this citadel of the animal system languish, and the enemies of human health will speedily attack the outposts, and make an easy conquest of the whole. Hence, of all the precautions which those who visit insalubrious climates may be required to adopt, the avoidance of every thing which is calculated to derange the digestive functions, is perhaps the most important. By a well-known law of the animal economy, every agent, how- ever deleterious, gradually diminishes, and finally almost destroys the susceptibility of the system to its influence, by long-continued or very repeated action. Hence, every agent will, cseteris paribus, manifest its operation with a promptitude and intensity, proportion- ate to the degree of previous immunity from its influence. It is this circumstance which causes the difference of predisposition to endemial fevers, between the acclimated natives of insalubrious regions, and strangers arriving from northern latitudes. This variety of predis- position depends in no degree on a want of constitutional vigour or general health. The robust and healthy are, in general, as much, if not more, under its influence, than the weak and infirm. By a gradual or protracted exposure to morbific agents, the animal economy loses, insensibly, its natural susceptibility to their influence. When such a change is effected by the combined operation of climate and endemial morbific agents, the system is said to be acclimated or seasoned, and the individual, thus seasoned, enjoys a comparative immunity from the diseases of the climate. Besides the foregoing source of predisposition to disease, from causes peculiar to hot climates, there is another and perhaps not less powerful one—namely, atmospheric heat. High atmospheric tem- perature is, strictly speaking, rather a predisposing than a morbific agent in relation to its influence on the human system.* In this re- spect it exercises a very powerful influence in the production of diseases. Long-continued exposure to an elevated degree of solar heat, tends, very considerably, to increase the general irritability of the system, and to lessen the power of vital resistance. Hence, the frequency of tetanus in hot climates, from injuries, or from the influ- ence of the cool and damp night air; and hence, too, the greater lia- bility to this and other irritative affections, during the hot seasons of our own climate, than in the cold months. Atmospheric heat tends, moreover, to predispose to fever, and other affections, by the profuse and continued perspiration it causes, as well as the redundant secre- tion of bile it is apt to excite. By these over-excited actions of two important organs, the general system is exhausted, whilst the organs themselves are rendered more susceptible to the injurious impressions of one of the most common and powerful exciting causes of disease— namely, cold. In relation to those predispositions to disease which are transmit- ted from parent to offspring, it may be sufficient to observe, in this place, that they depend, no doubt, on a peculiar physical condition or * Dr. James Johnson on Tropical Climates, &c. 46 CAUSES OF FEVER. intimate state of the organization, which we may Presume' of t^e to be imparted by the parent to the offspring, as the conto countenance, or of" the general structure of the body. Sect. II. Of the sources of Morbific Causes, and their general character. When we take a general survey of the source of all the possible causes of disease, we find that in relation to their origin, they range themselves under the following four general heads, viz : I. Recrementitious substances, which, in health, are separated and thrown out of the system, but being retained in the cir- culation, or reabsorbed, become a source of irritation to the sanguiferous system, and, therefore of, irritative diseases. These morbific causes are always secondary, being, them- selves, the consequences of an anterior injurious cause or impression. Thus the retention of the perspirable matter can occur only in consequence of the influence of some previous cause, adequate to disturb or arrest the action of the cutane- ous exhalents. The recrementitious fluids, which appear to be most injurious to the animal economy, when retained in the circulation, even in their elementary forms, are the per- spirable matter, the bile, and the urine; and of these the first is, perhaps, the most frequently concerned in the production of disease. The influence of causes of this kind in the de- velopment of disease, is, probably, much more exteusive than is generally admitted in etiological inquiries. In all that extensive class of febrile affections which arise from the influ- ence of cold, retained perspirable matter performs, probably, a principal part in the development of the irritative vascular excitement. Checked perspiration, or, more correctly speaking, inactivity of the cutaneous exhalents, constitutes the initial link in, perhaps, three- fourths of our febrile diseases. Let it not be imagined, that, as the recrementitious substances which are retained in the circulation are in a simple or elementary state, they cannot possess powers sufficient- ly irritating or active to excite morbid vascular action. In whatever form these substances may exist in the blood, they are still recremen- titious, and it is not to be presumed, that materials of this character could be long retained without an injurious influence on the animal economy. Accidental torpor of one emunctory is often vicariously supplied, by increased activity of another, and disease thus prevented. Thus if, after the cutaneous exhalents have been rendered torpid by a sudden influence of cold, the flow of urine becomes unusu- ally copious, disease will rarely ensue. Indeed, the all-wise and benevolent Creator has provided against the injurious conse- quences which must otherwise have resulted from the constant changes to which the function of the skin is necessarily exposed by * Richter's Specielle Therapie, vol. i. CAUSES OF FEVER. 47 placing in the interior an organ whose functions may, in a great de- gree, supply any accidental deficiency in the action of the former. II. Irritating substances generated within the body, but wholly independent of any organic actions. These causes of dis- ease are usually generated in the primae via?, and consist of worms, acids, mucus, and various other irritating substances, resulting from the fermentative or putrefactive processes. Worms have been, and by some are still considered as innocent inmates of the human body. This, however, is most certainly an erroneous sentiment. Without doubt, a few, or even a considerable number of worms lodged in the alimentary canal, may not be able to disturb the general system, when in a state of good health and con- stitutional vigour; but when the body is debilitated and irritable, as it commonly is during the period of dentition, the presence of worms in the intestinal tube will frequently give rise to the most alarming affections. Worms tend, moreover, to sustain and protract fevers produced by other exciting causes; an inattention to which fre- quently renders the progress of ordinary diseases peculiarly perplex- ing and unmanageable. It is not uncommon to meet with cases of slight febrile disease in children, from cold, which continue in spite of appropriate remediate efforts, gradually assuming the form of slow remitting fever, with a foul tongue, and gastric disturbances, and at last suddenly assume a favourable aspect, on the expulsion of a few large lumbrici. The agency of causes of this kind in the production of fever, was, however, formerly considered much more extensive than it appears, in reality, to be. Verminous epidemic fevers are described by some of the older writers, and saburral fevers were supposed, as it would appear, very common. Without ascribing so great an importance to these causes, as originators of fever, it is nevertheless unquestion- able that they do at times give rise to febrile affections, independent of all other morbific irritants. Their febrific tendency is, however, much more frequently mnnifested in the support, or additional vio- lence which they give to fevers arising from other causes, than in ori- ginating febrile affections by their own immediate influence. III. Morbific agents, generated out of the animal body, consist- ing either of deleterious substances floating in the air, or of the sensible properties of the atmosphere, or finally mecha- nical causes—namely: miasmata, noxious gases, heat, cold, electricity, humidity, and mechanical injuries, &c. IV. The fourth and last class of morbific agents comprehends those which are generated by morbid organic actions of the living system, constituting the various contagions. The principal causes, embraced under the last two heads, are so extensive in their influence on the human system, and so interesting and important, both in a medical and scientific point of view, that a separate and full exposition of their respective modes of origin, and physical, as well as morbific characters, will not be deemed inappro- priate in a work of this kind. 4S CAUSES OF FEVER. Sect. III. Atmospheric Temperature, and its relations with the Animal System. A certain quantity of heat is indispensable to life, throughout the whole range of organized beings. Every animated being possesses an inherent power to generate heat, and to resist, to a certain extent, the physical law of the distribution of heat; and, consequently, to maintain its peculiar or specific temperature, when placed in a me- dium either many degrees below or above its own temperature. The constant and rapid reproduction of heat by the vital powers, keeps up the natural temperature of the animal body although surrounded by a medium which abstracts its heat, with great rapidity. Such, in- deed, is the evolution of heat by the human body, that an atmosphere of the temperature of 98° is generally oppressive and unpleasant by the feeling of warmth which it causes, although at this temperature of the air, no heat can be communicated by the surrounding atmo sphere to the body. The temperature most grateful and invigorating to the human system, ranges from about 60° to 65°. " This tempera- ture of the air appears to abstract the heat of the body in about the same proportion in which it is generated in the healthy state of the system ; and this degree of the temperature is, therefore, the most congenial, for it neither exhausts the vital powers, nor gives rise to unpleasant sensations." There exists, however, considerable diversity in the human consti- tution, in relation to the power of supporting the extremes of tem- perature. This depends not only on the original vigour of the system, but also, greatly, on the influence of habit and modes of living. A person endowed with a vigorous constitution, and with habitual good health, will bear a degree of cold without any unpleasant feelings, which, to one of a feeble and exhausted system, will be a source of painful sensations and indisposition. Habit, in relation to previous exposure, has a powerful influence in varying the effects of tempera- ture on the animal system. The same temperature will cause feel- ings of severe cold or great warmth, according as the body has been previously exposed to a high or low temperature. Whenever the surrounding medium abstracts the heat of the body more rapidly than it is generated by the regular actions of the animal economy, the sensation of cold will be produced ; and the intensity of. this sensa- tion will always be proportionate to the rapidity with which the heat is abstracted, and the feebleness of the heat-generating power of the system. I. Physiological effects of cold.—When the temperature to which the human system is exposed, is so low as to give rise to the sensation of cold, its immediate effects are : 1. Diminution of the action of the cutaneous exhalents, and of the external capillary blood-vessels, giving rise to a pale, shrunken, and dry state of the skin ; 2. Dimi- nished action of the heart and arteries—manifested by'smallness, weakness, and slowness of the pulse. In relation to the effects of low temperature on the frequency of the pulse, however there ex- CAUSES OF FEVER. 49 ists some discrepancy of opinion among physiologists. From the experiments of Drs. Stock, Spooner and M'Donnel, it would seem, that although the strength and size of the pulse are diminished by cold, yet its frequency is considerably increased. Against these experi- ments we may oppose those performed by Currie, Rush and Klapp ;* and in my own experiments I have invariably found the pulse dimi- nished, both in frequency and in volume, when cold was applied to any particular portion of the body.t 3. Diminished sensibility of the external parts, passing by degrees throughout the whole system. Hence the benumbed state of hands, fingers, and other external parts, the torpor of the sensorial functions, and the sluggishness and feeble- ness of muscular action which occur from the protracted influence of severe cold ; and in this way, too, an almost irresistible inclination to sleep occurs when the cold is very intense. Artificial somnolency has been produced in certain animals by exposing them to a very low degree of temperature. 4. When moderately applied, cold increases the powers of the digestive organs. Hence the aphorism of Hippo- crates, Hieme ventres calidorus sunt. The appetite increases, and the process of digestion is performed more rapidly in moderately cold and dry than in warm weather. We are informed by Xenophon, that the Greek soldiers, on their return from Asia, were exceedingly harassed by the most severe sensations of hunger, while passing the snow-covered mountains of Armenia, although they were allowed their ordinary rations of food. When cold becomes very intense and protracted, however, the digestive as well as all the other organs of the system become enfeebled and inactive. 5. The sudden applica- tion of cold causes a hurried, irregular and imperfect action of the respiratory apparatus; and when intense, it checks or impedes the efforts to dilate the chest, and these effects increase, pari passu, with the increased influence of the cold, until at length respiration is per- formed so imperfectly as to prevent the due decarbonization of the blood, and the whole organization sinks into a state of torpor and insensibility. 6. Moderate cold is favourable to nutrition. " Man and all animals are fatter in winter than in summer ; and in the north than in the south." When, however, the cold is applied in an intense grade and prolonged in its influence, the process of nutrition is dis- turbed and interrupted. 7. The pulmonary exhalation, and the se- * That Dr. Stock and the other experimenters observed what they record upon this point, cannot be doubted. We can readily admit that when the body is sud- denly plunged into cold water, the mode adopted by them, the pulse will at first be accelerated. It must be observed that when the body is suddenly immersed in cold water, the blood is violently driven in upon the heart and larger vessels, and the respiration is performed in a hurried and imperfect manner, in consequence of which, the heart is excited into a temporary exertion to overcome the load which oppresses it, and the pulse consequently at first accelerated. t The pulse of the inhabitants of northern climates is habitually slower than the ordinary standard of frequency in the middle latitudes. Amongst the Green- landers, it is by no means uncommon to find the pulse as slow as 40 and 45 in a minute.—Beaupre on the Effects and Properties of Cold, p. 50. VOL. I.--4 50 CAUSES OF FEVER. cretion of urine are increased by cold, and supply, in a degree, checked exhalation by the skin from the same cause. Stringuntur tubuli pellis, coguntvr et intus Tott variis pellenda viis excreto, Ifc. 8. Cold, when prolonged in its influence, diminishes the venereal pro- pensity, (Montesquieu, Esp. des Loix, b. 14, c. 2,) but it does not appear to repress the function of generation ; for although the vene- real appetite be less constant and urgent in cold than in warm climates, yet the power of procreation would seem to be even greater in the former than in the latter. " In Sweden it is not uncommon to see women have twenty or thirty children ; and in Russia marriages are followed by a numerous progeny."* 9. Cold retards the develop- ment of the sexual organs, and the period of pubescence, more espe- cially in the female sex. In northern latitudes the catamenia rarely commence before the sixteenth or seventeenth year, whereas in the ardent climates o,f the intertropical countries, the menstrual evacua- tion is apt to make its appearance as early as the twelfth, and not unfrequently as early as the tenth year of age. Cold is, therefore, a sedative agent; for, although, when moderately and transiently applied, it is generally followed by phenomena at- tributable to a stimulating influence; yet these are not, strictly speak- ing, the immediate consequences of the low temperature, but rather of the reaction of the vital energies, after the temporary reduction of their activity by the cold. When an agreeable glow, and aug- mentation of the general vigour are experienced after leaving a cold bath, they arise, probably, not from the direct stimulus of the cold, but from its having depressed the excitement of the surface, and increased the susceptibility to the action of stimuli; in consequence of which the ordinary influence of the atmosphere, the warmth of the clothing, and even the stimulus of the blood, as well as exercise, and other usual exciting influences, will cause an increased degree of excite- ment, more especially in the cutaneous capillary system. That the phenomena of increased activity and vigour, which sometimes ensue, are solely the consequence of a reaction in the system, after the cold has temporarily diminished the excitement, and thereby increased the susceptibility to subsequent excitation, is fully demonstrated by the fact, that unless the system be endowed with a considerable degree of energy and activity, no such favourable effects will follow the application of cold. If cold produced these effects by its stimulating powers, it would, one may reasonably believe, produce them when the system is in a state of feebleness; because mere weakness can * Beaupre on the Effects of Cold, &c, p. 18. " In the coldest regions, approach- ing the poles, excessive cold retards the generative flame, and, we may say ex- tinguishes the lamp of physical love. Beyond the 65th degree of latitude popu- lation continues to decrease, and ends at Spitzbergen and Nova-Zembla. Lapland and Iceland females are said to menstruate but little; they are apathetic in love and know but little of the bitter feelings of jealousy, or the vehemence of sexual attachment." CAUSES OF FEVER. 51 never annul the operation of a stimulus, provided the excitability be not exhausted. That cold must necessarily diminish the actions of the system, is evident from its being, in fact, nothing else than a com- paratively diminished grade of temperature. For if heat be a stimu- lus, it is manifest that this stimulus must be lessened in its powers, just in the ratio in which its intensity is decreased. Thus, if 80° produce a certain degree of excitation, 60° (cseteris paribus) must produce a less degree and 40° still less, and so on. Correctly speak- ing, every agent capable of affecting the animal economy, is a stimu- lus; but when we speak of cold and its effects, it is to be always understood in a relative sense; for when it is said that cold is a seda- tive, it can mean nothing else than that it is less stimulating than a higher degree of temperature. It is to be observed, however, that although cold unquestionably tends to diminish the actions of the system, yet, when applied sud- denly, it often manifests a very conspicuous exciting agency on the nervous or sensitive system. Thus, a few drops of cold water sprin- kled on the face of a person in a state of syncope, or approaching to this state, will generally produce immediate excitation and return of consciousness. In asphyxia from carbonic acid, or electricity, too, cold water dashed on the face and breast, often causes immediate re- spiration, and other manifestations of returning life. In cases of this kind, the sudden sensation which the cold produces, acts, probably, as the exciting cause. 2. Cold as a morbific agent.—Cold is, perhaps, the most common and frequent of all the remote causes of disease in the temperate latitudes. Its injurious tendency appears to be much enhanced by being conjoined with humidity; for, a very dry and cold, air is far less capable of abstracting the animal temperature than low tempe- rature united with humidity. But the most important circumstances which render the impressions of low temperature prejudicial to the animal economy, relate to the previous condition of the system itself, with regard to the cutaneous transpiration, and antecedent exposure to high temperature. The morbific influence of cold is always efficient in proportion as the body has been previously exposed to an elevated temperature ; and, more especially, in proportion as the perspiration is more or less copious. The most powerful of all the predisposing conditions of the animal system to the injurious effects of cold, is a state of free perspiration, from fatiguing and exhausting exercise or labour, under the influence of high solar heat. In this state of the body, and scarcely in any other, the sudden application of cold to a large extent of the surface, or to the stomach, in the form of ice or cold water, will often suddenly produce the most alarming, and even fatal, consequences.* When the animal tempe- rature is not rapidly carried off by free perspiration, and the system not debilitated by fatigue, cold can never give rise to such sudden, violent, and dangerous consequences. The effects here alluded to, as resulting from the impressions of cold, while the body is in a state * Rush's Medical Inquiries. Currie's Medical Reports. 52 CAUSES OF FEVER. of free perspiration, from fatiguing exercise and atmospheric > appear to be of a nervous or spasmodic character, consisting g' ' rally in sudden prostration and effacement of the vital energies 01 me system. As a febrific cause, cold plays a very important part in me production of disease. It is not, however, merely as cold, or low temperature, that it is most influential as a febrific cause ; vicissitudes of temperature, sudden changes from warm to cold, or from cold to warm weather, are the sources whence febrile disease is so abun- dantly derived; and these changes are always injurious in proportion to the suddenness of the transition, and the greatness of the change. A very gradual change of atmospheric temperature rarely produces disease, except in such as are peculiarly predisposed to influences of this kind. The mode in which cold produces fever has already been explained. Its first effects on the system are torpor of the cutaneous exhalents, and a retreat of the blood from the surface to the internal organs. The recrementitious perspirable matter is thereby retained, and the blood rendered more irritating, or at least, surcharged with offensive substances. In consequence of these morbid conditions, the heart is excited into increased action, by which the blood is again propelled into the external capillary system, without, however, over- coming the torpor of the exhalents. If any portion of the capillary vessels be predisposed, by previous debility, to morbid excitement, high vascular irritation will be apt to occur in this part, and probably to the extent of actual inflammation. Should the mucous membrane of the respiratory passages be predisposed to irritation, catarrhal or pneumonic affections will be the consequence. If the alimentary canal be in a state of accidental or habitual irritation, dysentery or enteritis will probably occur. In short, whatever part of the system may be in a condition peculiarly predisposed to disease, inflammation or high vascular irritation will most likely be developed in it, by the increased momentum of the circulation, and the immediate local im- pressions of the recrementitious elements retained in the circulation.* When the degree of cold is excessive, or very prolonged in its action on the animal system, it gradually abstracts the animal tem- perature to a degree incompatible with vital action, and asphyxia, gangrene, or death ensues. The tendency which very low tempe- rature has to produce these effects, is greatly controlled by the degree of constitutional energy, as well as the degree of corporeal exercise, of those who are exposed to its prolonged influence. A person of a vigorous and healthy habit of body, will readily bear a degree of cold without particular injury which would soon destroy an indivi- dual of a weak and infirm state of the system. In all instances where cold is applied in a degree capable of gradually reducing and finally arresting the vital actions, an indomitable inclination to sleep super- venes just before the fatal torpor comes on. When this oppressive somnolency ensues, all feelings of pain or suffering cease__and if it be not resisted, death is inevitable. Heat.—High atmospheric temperature acts much more frequently Dr. James Johnson, passim. MIASMATA. 53 as a predisposing than an exciting cause of disease. « Solar heat," says Dr. James Johnson, "produces only the predisposition, while terrestrial exhalations and cold call into action the principal diseases of hot climates. The mode in which solar heat contributes to the production of disease, appears to be either by augmenting the general irritability of the system, or more generally, by exciting inordinate functional action of the skin and the liver, and thereby rendering them more susceptible of the paralyzing impressions of cold. Be- tween the skin and the liver there exists a close and powerful sym- pathy, in consequence of which, whatever excites the functions of the former, produces, perhaps, an equal increase of the functions of the latter organ."* Hence, high atmospheric heat very generally produces an increased secretion of bile, by its influence upon the liver through the medium of the skin, whose functions it is so peculiarly adapted to augment. It is manifest that an inordinate activity of these two functions from the influence of heat, must render them ex- tremely obnoxious to torpor or inactivity from the sudden application of cold; and it is equally obvious, that a sudden torpor of these two important emunctories cannot occur without an immediate injurious consequence upon the whole system. Solar heat is, moreover, ex- tensively concerned as an indirect cause of febrile affections, by fa- vouring the production of marsh miasmata. By its expansive and exciting influence, it sometimes gives rise to sudden and dangerous local determinations, particularly to the head, causing apoplexy, and that state of cerebral oppression called a stroke of the sun. Sect. IV.—Of Miasmata. The term miasmata is here used as designating a highly important class of febrific agents of a gaseous form, which act on the animal system through the medium of the atmosphere. This class of agents consists of two orders, namely;—1. Infection, comprehending those febrific efliuvia which are generated by the decomposition of vegeta- ble and animal matter; and—2. Aeriform contagions, generated by the animal system in a state of disease. 1. Infection, or that variety of febrific agents which is produced by decomposition out of the animal system, consists of two genera, namely; — 1. Those which result from the humid decomposition of vegetable and animal substances contained in the public filth of cities, in marshes, and in other soils and situations furnishing these mate- rials. This genus is usually designated by the term marsh miasm ; but from the common or public source of these morbific effluvia, it has been proposed, and by some adopted, with much propriety, I conceive, to distinguish them by the compound term koino-mias- mata. 2. Those febrific efliuvia which are generated by the decom- position of the natural exhalations and excretions of the human body, accumulated and confined in crowded and ill-ventilated habi- tations. These deleterious effluvia, originating from the decomposi- * James Johnson, On the Influence of Tropical Climates, fyc. 54 MIASMATA. tion of matter derived from the human body, have, with equa_P ^ prietv, been designated by the term idio-miasmata, expressive ^ personal or private character of their source.* Before trea 1 g these febrific agents, in an etiological point of view, it will be Pr<->P^ to describe, more circumstantially, the manner and circumstances in which they are generated, as well as their physical characters, so iar as these can be known. , I. Koino-miasmata, usually designated by the terms marsh-mias- mala, or malaria. This morbific agent was not unknown to tne ancient Greek physicians. They personified it under the emblem ol a many-headed monster, whose devastating influence was so severely exercised over the luxuriant fields of Argolis, that it was made one of the labours of the potent son of Alcmenus to rid the country of this dreaded source of pestilence. Hercules, accordingly, drained the extensive Lernean marshes, and thus dried up this abundant source of pestiferous emanations. Heat and moisture are indispensable to the generation of koino- miasmata ; without these, no decomposition can take place, and with- out decomposition no deleterious agents can be generated from dead vegetable and animal substances. In latitudes where the atmospheric temperature seldom rises above 60°, the diseases which arise from this agent occur but very rarely, and perhaps, never in an epidemic man- ner. The Lithuanian marshes of Russia do not render the surround- ing districts insalubrious. It would seem, indeed, from a long series of observations, that koino-miasmata are seldom evolved to a de- gree sufficiently copious or active to create extensive disease, so long as the temperature of the air does not rise above 80° of Fahrenheit. It is, however, not necessary that moisture should be present in great abundance for the production of miasmata. Indeed, grounds com- * These distinctive terms were originally proposed and adopted by the late Dr. Edward Miller, of New York, in the year 1804. He observed that there were two species of miasmata; the one consisting of febrific exhalations from marshes and other soils, and the other of effluvia generated by the decomposition of per- sonal and domestic filth. " In order to distinguish these two varieties of miasmatk agents, and, at the same time duly to fix in the mind the impression of the origin and production of them, it is judged expedient to designate each by terms which will, invariably, express the process of nature in their formation. As the Greek language has been generally resorted to in the framing of scientific nomenclature, I shall employ the adjective koinos, common or public, to denote one species of miasma, and iaioi, personal or private, to denote the other. The application of these terms will be readily understood. That portion of the air charged with mi- asmata, exhaled by solar heat, from the surface of swampy ground, or from masses of filth overspreading the open area of cities, according to this distinction, is de- nominated Atmosphera koino-miasmalica. And that other small portion of air con- taminated by miasmata, emitted from, and surrounding the body, clothes bedding, and furniture; of persons immersed in the filth of their own excretions and of those associated in the same family with them, accumulated, long retained and acted upon by animal heat, is denominated Atmosphera idio-miasmatica;7__Attempt to deduce a Nomenclature^ fyc. Med. Repository. New York, 1804. MIASMATA. 55 pletely covered with water, send forth but very little of this dele- terious effluvium, however favourable the temperature, and other circumstances may be. Hence, copious and continued rains by inun- dating marshy soils, render such localities comparatively salubrious, (Dalzille, Ferguson). Ferguson was led to infer, from his observa- tions on this point, that miasmata were extricated wholly indepen- dently of the humid decay or decomposition of vegetable and animal matter, and apparently without the agency of humidity. He asserts that this aeriform poison is never extricated, in any considerable quan- tity, until the moisture of the soil is so far dissipated as to leave the ground in the last stage of the drying process. This, however, is de- cidedly contradicted by almost universal experience. In proof of his opinion, among other observations, he says : " In the months of June and July our army marched through the singularly dry, rocky, and elevated country on the confines of Portugal, the weather having been previously so hot, for several weeks, as to dry up the mountain streams. In some of the hilly ravines, that had lately been waterT courses, several regiments took up their bivouac, for the sake of being near the stagnant pools of water that were still .left among the rocks. Many men were seized with intermitting fever." From this, and similar facts, he thinks himself warranted to conclude, that the humid decay of vegetable and animal matter has no immediate agency in the production of miasmata, and that moisture, particularly, is not essential. But " half dried ravines and stagnant pools of water" are surely no evidence of a want of humidity, and present, one should think, precisely the conditions most favourable to the emission of mi- asmata from vegetable and animal decomposition. It may be observed, that in every instance adduced by Dr. Fergu- son, in proof that the extrication of miasmata does not depend on the humid decay of vegetable and animal matter, the soil from which the miasmata were emitted had been previously thoroughly saturated with water, during the rainy season, and moisture must, therefore, have existed in sufficient abundance, a short distance under the sur- face of the soil, however parched the latter may have been. Under such circumstances, miasmata might be abundantly sent forth, with- out any obvious humidity and vegetable decomposition, on the sur- face ; for the vegetable and animal remains, collected during the rainy season, must have been gradually decomposed during the drying process, and left, in part, at least, mingled with the portions of the soil on the surface. In this state, then, the slow evaporation of the humidity under the surface, in passing up into the air, would dissolve the putrid but dry particles of animal and vegetable remains, and convey them in the form of an effluvium into the circumambient atmosphere. That a considerable degree of humidity is especially favourable, and even essential, to the evolution of miasmata, is evident from the circumstance that marshes, stagnant pools, and the oozy shores of rivers, have, in all ages, and in all countries, been found the most insalubrious portions of the earth during the hot seasons. As to the variety of soil most favourable to the production of 56 MIASMATA. miasmata, we possess no very definite or certain information, it as been asserted, that an argillaceous soil is most favourable for the ex- trication of this effluvium ; but its tendency in this way appears to depend solely on its greater compactness, in consequence ol which, it retains humidity much longer than other soils, and thus favours the formation of marshes, and of standing pools of water. It is not, however, from marshy or low and humid soils alone, that this morbific effluvium is disengaged ; for « there is scarcely a spot of this earth's surface to be found that is not covered or imbued with both vegetable and animal remains in a state of decomposition, and ready to afford pabulum for the sun's rays, with or without humidity to extricate malaria.* Wherever vegetable matter meets with sufficient heat and moisture to cause it to enter into humid de- composition, there miasmata will be evolved, and in our own climate there are very few, if any situations, that do not at times furnish all these conditions to a greater or less extent. A mixture of fresh and salt water in marshes, appears to enhance the copiousness and virulence of miasmata to a very obvious degree. It is a singular fact, that the water of the sea is much more apt to enter into putrefactive decomposition than fresh water ; and this, no doubt, depends on the great quantity of organic matter which it con- tains. M. Monfalcon mentions some interesting examples illustrative of this fact.t The extensive pool of Valdec, in the south of France, is quite saline. Not more than a few rods from it is a large pool of fresh water called Engrenier. When the waters of these two pools rise, and run into each other, as they occasionally do, much sickness soon occurs throughout the adjoining parts. In the vicinity of Lukes, on the south of the Ligurian Appenines, there is a large marshy plain accessible to the high tides of the ocean. The neighbouring districts were almost uninhabitable from the pestilential effluvia which ema- nated from this marsh, until the waters of the sea were separated from the sweet water of the marsh by means of sluices and hydraulic works, when it became healthy, and the population increased rapidly. Of the nature of koino-miasmata, we possess, as yet, no certain knowledge. Examined chemically, the air of the most pestiferous marshes is found to differ in nothing from the purest and most salu- brious air. According to the experiments of Professor Julia, of Lyons, it would appear that 1. The deleterious influence of koino-miasmata depends on par- ticles of putrid animal or vegetable matter dissolved and sus- pended in aqueous vapour. 2. The air of marshes does not differ from atmospheric air in any of the principles which chemical analysis can detect. 3. None of the gases disengaged from bodies in a state of putre- faction, exhibit themselves in a sensible quantity. 4. The disorders caused by koino-miasmata are not in any de- gree dependent on the predominance of azote, of carburetted hydrogen, of ammonia, of nitrous oxide, &c., in the air. * Dr. James Johnson, Med. Chir. Rev, t Histoire Medicale des Marais. Paris, 1828. MIASMATA. 57 That koino-miasmata consist in particles of putrid vegetable and animal matter, dissolved in aqueous vapour, receives considerable support from the experiments of Gaspard and Majendie on the effects of putrid exhalations on animals, and which have already been cited in a former part of this volume. Majendie found, that on exposing different animals to the exhalations of putrid animal matter, affections were produced analogous to those which are known to occur in man from the influence of pestilential miasmata. It is not improbable, there- fore, that such putrid materials, suspended in vapour, constitute the deleteriousprinciple of miasmata of this kind; and it may be reasonably presumed, that the different modifications of disease produced by this agent, in different localities, depend in a great degree on the different degrees of concentration, as well as on the particular character and proportion of the substances from whose decomposition the putrid miasmal particles are derived. It can hardly be doubted that the relative proportions of animal and vegetable matter which may enter into miasmal exhalations, will determine the violence of their influ- ence, and modify its results on the system. Plausible as these senti- ments may be, it should not be forgotten that they are founded on no certain data, and that we may, after all, as yet be remote from the truth in relation to this subject. Whatever may be our views concerning the essential nature of koino-miasma, observation has made us acquainted with certain of its physical properties, as well as with its general effects on the human system, and which is perhaps all that it imports us, in a practical relation, especially to know. Koino-miasmata possess a greater specific gravity than atmospheric air (De Lisle). They cannot, consequently, ascend into the air with- out being attached to and carried up by lighter bodies: and these vehicles consist, without doubt, of aqueous vapours. Hence, persons sleeping in elevated chambers, are much less apt to contract miasmal diseases than such as are lodged on the ground floor (Hunter on the Diseases of Jamaica, Blane, Lempriere,* De Lisle). And hence, too, the greater salubrity of hills, and very elevated parts, than the ad- joining low grounds. The ancient Romans appear to have been fully- aware of this fact, and they availed themselves of it by almost uni- formly selecting very elevated positions, or hills, for the sites of their towns. It is true, that some very remarkable exceptions have occurred to this fact. Bancroft mentions the great mortality which has repeat- : edly been observed on the top of Montefortune, at St. Lucie : and on the Hospital and Richmond hills, at Grenada, while the surrounding low situations were comparatively salubrious. Dr. O'Hallaran, in his account of the yellow fever of the south and east coasts of Spain, mentions similar examples of the great prevalence of miasmal dis- * Drs. Blane and Lempriere, in their report to the Secretary of War concern- in" the Walcheren fever, observe: " On no account should ground floors be used to sleep on: the more lofty the buildings the better, for the tenants of the upper stories not only enjoy the best health, but, when taken ill, have the disease in the mildest form."—Bancroft on Marsh Exhalations. 58 MIASMATA. eases on very elevated situations, whilst the surrounding marshy grounds were but little infested with this deleterious effluvium, ne refers particularly to Monjui, a hill 700 feet high, overlooking Barce- lona, the air of which, he says, is so deleterious, that it was lound necessary to relieve the stationary guard every eight or ten days ; and, he adds, that the injurious influence of the exhalations arising irom the swamps below manifested itself more conspicuously upon the summit of the hill than in the subjacent parts. Dr. Blane, who men- tions similar facts, explains them by supposing that the vapours formed on the low and swampy grounds ascend, and, with the miasmata which they hold in solution, pass over the lower situations, and im- pinge and settle on the neighbouring hills. It is, indeed, by no means uncommon to see fogs, which rise out of the low grounds, ascend and hover over the tops of the neighbouring mountains, and it may well be presumed that these fogs will convey along with them a large por- tion of the miasmata which may be extricated from the same grounds whence the aqueous vapours rise. Koino-miasmata are abundantly precipitated to the surface of the earth during the night, and more especially during the first hours after the setting, and shortly before the rising of the sun. Hence, in part, the greater liability of contracting miasmatic diseases from ex- posure between the setting and the rising of the sun than after the sun is considerably above the horizon (De Lisle, Bancroft, Sir James Fellows, Johnson). The most dangerous point in the twenty-four hours of the day is " that which accompanies the setting and that which immediately precedes the rising of the sun, and the least critical time is when the sun is at its highest point above the horizon" (De Lisle). In these facts we have strong evidence of the correctness of an observation already made—namely, that the miasma is united with and suspended in the air by aqueous vapour, which, falling in the form of dew, carries down along with it the deleterious miasma- tic particles. Koino-miasma may be arrested in its progress or passage from its source to other parts, by whatever is capable of impeding and in- tercepting the progress of aqueous vapour. Thus the interposition of a dense forest, of a high wall or fence, of a chain of elevated hills, in short, of any mechanical obstacle of this kind, has been known to protect the inhabitants of villages, of camps, of convents and of single habitations, from the pestiferous influence of neighbouring marshes. De Lisle relates several very remarkable facts illustrative of this observation (Monfalcon, Bancroft). A convent situated on Mount Argental, near the village of St. Stephano, was, for a long time, remarkable for its salubrity, until the trees by which it was sur- rounded were cut down, when it became extremely sickly. From the same circumstance, miasmata are sometimes confined by obstacles of this kind, and so accumulated in particular localities, as to acquire a high degree of concentration and power. Marshes surrounded with dense forests, in warm climates, have often given unequivocal illus- tration of this fact. The same effect, in causing a stagnation and accumulation of miasmata, has been observed in most situations MIASMATA. 59 environed by high hills. In some of the valleys in the mountainous regions of South America, malaria are thus accumulated to a degree which gives them the utmost virulency, while the surrounding ele- vated parts are entirely free from miasmal diseases. This is remarka- bly the case of Acapulco, which, as Dr. Macculloch* observes, may be regarded as a striking instance " of the imprisonment of malaria by hills." It is in this way, too, says this writer, that we <; may explain the peculiar virulence of jungles and pine swamps and even of woods everywhere." Considerable diversity of opinion has been expressed as to the dis- tance to which miasmata may be diffused from their source in a state of sufficient concentration, to produce fever. In a quiescent state of the atmosphere, the sphere of activity is probably much more limited than has been generally supposed. Bancroft thinks that they are rarely carried beyond a quarter of a mile, even by unobstructed cur- rents of air, in a state sufficiently active to produce fever; and he adduces several observations which seem to confirm this opinion. Unquestionably, however, currents of air passing over marshes often convey the miasmata which arise from them to a very considerable distance—sometimes several miles, in a state of concentration fully adequate to the production of their usual deleterious effects on the human system. " In Italy," says Dr. Macculloch," the poisonous ex- halations of the lake Agnano reach as far as the convent of Camal- doli, situated on a high hill, at the distance of three miles, proving that thus far, at least, malaria can be conveyed by the winds." The account of the thirty Roman noblemen, mentioned by Lancisci, is an interesting and striking illustration of this fact. They were sailing near the mouth of the Tiber, on a party of pleasure. Suddenly the wind shifted, and blew over the putrid marshes. Twenty-nine out of the thirty were soon seized with intermitting fever. The effects, often truly frightful, of the harmattan, after becoming loaded with the pestilential effluvia of the swamps of Benin, afford also a strong illustration of this fact. From this circumstance it not unfrequently happens that those who reside on the leeward margin of marshes, or sluggish streams, are extremely harassed by miasmal diseases—while those who sojourn on the windward side remain almost entirely ex- empt from these affections. Dr. Macculloch relates an instance from his own observation, which strikingly illustrates this fact. " An army was encamped in a very pestiferous plain, yet the health of the men did not suffer, because, being near the shore, the sea-breezes predomi- nating at that season, swept back the malaria into the interior coun- try. From some cause the encampment was transferred to another point, without recollecting that the change of the regular winds was approaching. They did commence —sweeping in a new direction across the plain; and, within a few days, many thousand men were disabled or destroyed." During the autumns of 1820, '21, '23, and '24, there was scarcely a family between the eastern shore of the Schuylkill and the city * An Essay on the Production and Propagation of Malaria, &c. 60 MIASMATA. of Philadelphia, that did not suffer from intermitting and remitting fevers; whilst among the inhabitants of the western shore, and of the high grounds a short distance back, there was, comparatively, but little sickness. The cause of this difference manifestly consisted in the course of the wind, which, during the periods here mentioned, as indeed is generally the case, blew almost continually from the west, northwest, or southwest; and thus swept the miasma, which was generated along the oozy borders of the Schuylkill, in an eastern direction. Violent storms, and copious showers of rain, tend powerfully to free the atmosphere from koino-miasmata. The former violently disperses them, and the latter sweeps or washes them down to the surface of the earth. Nothing is more common than to find mias- matic epidemics to remit immediately after copious floods of rain or violent storms (Rush, Bancroft, Monfalcon). A humid air is a much better vehicle for the transportation of mias matic exhalations than a dry one. The particles of the miasmatic poison attach themselves to the humidity of the air, and are thereby carried along by currents of wind. It is to be remarked, however, that, although atmospheric humidity appears to favour the dissemi- nation and action of miasmata, yet observation would seem to show that when these effluvia pass over a surface of water, they become absorbed, or in some way lost. This circumstance may, in part, account for the short distance assigned by Bancroft to the dissemina- tion of miasmata from their source; for in all the examples which he adduces in support of this opinion, the miasmata were conveyed over bodies of water. II. Idio-miasmata.—This variety of miasmata is generated by the decomposition of the matter of perspiration, and the other excretions of the animal body; and hence it most frequently occurs in the con- fined and crowded hovels of the poor, in crowded jails, ships, hospitals, and wherever many individuals are confined in apartments not duly ventilated. From an inability to procure separate dwellings, the poor are generally obliged to take up with small apartments, into which two or three families are often crowded; and in order to save fuel, and indeed frequently from the total want of fuel, every access of the external cold air is carefully cut off. Add to this the filth and want of proper changes of clbthing, almost inseparable from extreme poverty, and you have a combination of circumstances peculiarly calculated to generate a miasma, by the putrefactive decomposition of the animal exhalations with which the air and every article of clothing in such apartments must be saturated. It is chiefly during the cold season of winter that this variety of miasmata is generated. When the weather is warm, the air of crowded and filthy apartments is constantly renewed by the doors and windows being kept open, and the accumulation and stagnation of the animal exhalations thereby prevented. Dr. Smith observes, that this miasm is especially apt to be generated in the apartments of the sick, particularly "of those who are labouring under the typhus state of fever."* It may be * Elements of the Etiology and Philosophy of Epidemics, p. 52. MIASMATA. 61 :: observed, however, that the exhalations which emanate from the body ! in a slate of disease, and which possess the power of producing the same disease as that, under whose influence they are evolved, cannot, with strict propriety, be ranked with the present class of miasmal f poisons. They belong to the contagions. I would restrict the term t idio-miasma to those morbific effluvia which are generated by the decomposition of the animal secretions, whether formed in a state t of health or disease, and to the ordinary exhalations from the body, when accumulated in such a manner as to deteriorate the atmosphere I of confined rooms, if these be really capable in themselves, and with- ■f out decomposition, of exciting fevers. Idio-miasmata are always quite limited in the sphere of their in- t fluence. Beyond the room or habitation in which they are generated is their operation cannot extend; unless, indeed, they are absorbed or adhere to articles of clothing, and are conveyed abroad in a state of i sufficient activity to act on the human system. Whenever fever is i found to spread from a source of idio-miasmata, it is in consequence, [• doubtless, of the generation of a new contagious miasm by the disease, ? which is produced in the first instance by the idio-miasmatic poison. ie I am well aware that this opinion involves what has been declared i a manifest inconsistency—namely, the origination of a contagious * disease by a common or general exciting cause. All such objections, r founded merely on speculative inferences, may be met by facts, which lf must stand good, however irreconcilable they may appear to be with it the dogmas of philosophy, or with admitted principles. It is a fact, j; for instance, that typhus may be originated by the miasm resulting from the decomposition of the secretions or exhalations of even healthy r individuals, crowded and confined a long time in narrow and unven- j tilated apartments. And that, although not necessarily a contagious 1(. malady, typhus may, under peculiar circumstances, generate a specific f virus which is capable of exciting the same disease in others, is a fact supported by a mass of testimony which cannot be reasonably , rejected. " There are few physicians," says one of the most eminent medical writers of the present day,* " who believe that epidemic or , endemic fevers arise from specific contagion, though facts daily teach us that typhus, yellow fever, dysentery, &c, occasionally, and under ! particular circumstances, give out a something (call it what you .'.. please), which produces a similar disease in the healthy stander-by, i who happens to come within its range. If we may venture to prog- "j nosticate, we would anticipate that this will &e,asit assuredly now is, j. the more general opinion among practitioners." From the circumstance of this variety of miasmatic poison " be- 1 coming innoxious when diffused in the atmosphere, even a few feet 3 beyond the apartments in which it is generated," none of the forms ] of disease, which it is capable of producing, are apt to occur epidemi- cally. Typhus, nevertheless, has been known to occur in a manner ft well entitled to the name of epidemic. The late widely-spread epi- l demic of Ireland was surely strongly characterized in its progress and * Dr. James Johnson, Med. Chir. Rev., vol. vii. (1825,) p. 65. 62 MIASMATA. extent of diffusion by everv feature which can give to diseases he character of an epidemic. 'Though engendered and nursed in trie lap of wretchedness and poverty, it did not, in its desolating sway, fall exclusively upon those who were suffering under the distressing privations of penury. Its fatal visitations were abundantly made to the ample and airy habitations of plenty and comfort, and almost- ------sequo pulsat pede pauperum tabernas Regumque turres. The question here occurs: "If idio-miasma becomes innoxious by being diffused in the atmosphere even a few feet beyond the apart- ments in which it is engendered," how can typhus, which is mani- festly originated by this effluvium, become epidemic, or be produced in large and well-ventilated dwellings remote from the usual sources of this miasm ? Is it by the idio-miasma attaching itself to the clothes of individuals, or to other substances by which it may be con- veyed from one to another place ? If this be admitted, then idio- miasma must possess the character of a contagion. Is it not more probable, that in the majority of instances of this kind, the disease is propagated by a specific virus, generated by a morbid secretion, and conveyed as other contagions of an aeriform character are conveyed ? It does not seem probable that idio-miasmata can be disseminated by fomites. If it can be so disseminated, it must possess all the charac- teristics of a veritable contagion. Of the relations of Miasmata to the Jlnimal System, fyc. Having given an account of the physical character and conditions under which the two infectious effluvia, koino and idio-miasmata, are evolved, I proceed to the consideration of their relations, as mor- bific agents, with the human system, as well as with each other. Upon this subject I stand largely indebted to the ingenious and truly philo- sophical work of Professor Smith, of New York ; for, although 1 have long since entertained similar views in relation to the combined agency of these miasmal poisons in the production of fevers, yet the enlarged, systematic, and precise views taken of this subject by Dr. Smith, have afforded me some new and interesting insights into this part of the etiology of fevers. The class of fevers arising from koino-miasmata are very distinct in their general character, and we may presume, in their essential natures, from those which are the result of idio-miasmata. The former give rise to intermittent, remittent and bilious fevers ; and the latter miasm is the source of typhus, and the low nervous fevers of former writers. The deleterious power of koino-miasmata is manifested not only by the violent and fatal fevers which they are known to produce so abundantly, but also by the more slow inroads 4hey make on the physical and moral condition of those unfortunate beings who are habitually exposed to their influence. The indigenous inhabitants of marshy districts, in warm climates, present an aspect of suffering and MIASMATA. 63 wretchedness from this cause which is well calculated to draw forth the commiseration of those who are more fortunately located. Con- tinually exposed to the deleterious influence of these baneful exhala- tions, man, in such situations, exhibits a state of feebleness and early decrepitude, strongly indicative of a broken-down constitution, and deep, irremediable chronic disease. So deep and pervading, indeed, are the effects of malaria on the human system, that it never fails to debase, in a remarkable manner, both the physical and moral consti- tution of a people, who, through successive generations, reside in situa- tions abundant in perennial sources of miasmata. Not only does the stature and symmetry of the body suffer conspicuous deterioration, but the mind becomes torpid, feeble, pusillanimous, and the moral sentiments debased. But while such chronic and constitutional effects are wrought by the habitual endurance of koino-miasma, the system loses its sus- ceptibility of "being excited into those violent commotions of febrile action which this agent is so apt to produce in individuals less accus- tomed to its impressions. The natives of marshy districts are com- paratively much more rarely affected with the higher grades of mi- asmal fevers than those who are only occasionally brought within the sphere of its influence. In the former, the agency of this poison pro- ceeds as it were by a slow and concealed combustion, whilst in those who are not accustomed to its influence, its effects burst out in a raging and rapidly consuming flame. There can be but little doubt that koino-miasma varies in its powers, and often very considerably, according to various circum- stances in point of locality, and the relative proportions of the animal and vegetable matter which supply the materials for its composition. Dr. James Johnson, whose authority I am always disposed to respect, has expressed his belief in the occurrence of such diversities in the peculiar morbific powers of this agent. "The fever of Batavia," he observes, " differs from the fever of Walcheren—the fever of Antigua, from the fevers of the Ganges—and all these differ materially from the plague of the Levant." That certain countries and localities have an especial tendency " to generate one mode or variety of fever, while, in other situations, some other variety as exclusively prevails," is an observation founded on abundant testimony of unquestionable authority. In Germany, intermittents almost universally assume the tertian type ; in Italy, the quotidian type greatly predominates ; and in Hungary, paludal fevers are peculiarly apt to be attended with petechise. " The fevers of the Pontine marshes are noted for the short- ness of their intermissions; whilst Holland is not less remarkable for the variety of the types than the slow progress of the fevers. In Spain, as in Africa, the West Indies, and the southern parts of the United States, the black vomit and the yellowness of the skin are similarly characteristic symptoms."* Even in localities situated within a short distance from each other,(the most remarkable difference occurs in the character of the fevers which they engender. Thus, " the fevers * An Essay on Malaria, &c, by John Macculloch, M. D. 64 MIASMATA. of Walcheren," says Dr. Macculloch, "differ materially from those of Bresken on the opposite shore of the Scheldt; and in France ttiose of Rochefort differ as completely from those of the Lyonnais. It cannot be presumed that the relative proportions ol animal and vegetable matter should be the same in different localities, and equally improbable is it that the same kinds of these materials should be pre- sent in the different situations where miasmata are generated. 1 here must be great diversity in both these respects, and a corresponding diversity in the essential morbific qualities of the miasmata evolved from them. I have already mentioned the experiments of Majendie in relation to the effects of putrid animal substances on the animal system. From these, it appears, that" different kinds of flesh, when in a putrid state, produce different effects on the animal ecomomy,"* and it is, therefore, reasonable to conclude that miasmata will differ in their powers according to the greater or less proportion and kinds of the animal and vegetable matters concerned in their production. The influence of koino-miasmata on the human system, like that of other general causes of disease, is much under the control of the physiological state of the animal economy, of idiosyncrasy, of tem- perament, predisposition, and of accidental external causes. Thus of a number of individuals exposed for a certain time to the same miasm, some may become affected with intermittent fever, others with mild remittent fever, some with malignant bilious fever, some with bilious colic, some with dysentery, and others, perhaps, will escape the disease entirely. The influence of high atmospheric temperature in predisposing the system to the deleterious impressions of miasmata is, probably, very considerable. Long-continued exposure to solar heat appears to have an especial tendency to affect the biliary organs, and to render the system generally irritable. These conditions, it may be presumed, are peculiarly favourable to the morbific influence of malaria; and it is not improbable that they sometimes contribute, in a considerable degree, to render the miasmatic fevers of intertropical or hot climates, so peculiarly violent and dangerous. Dr. Macculloch dwells much on " errors of diet" as a predisposing cause of the miasmal fevers. It would appear, that the free use of animal food, in tropical climates, is peculiarly calculated to favour the morbific influence of miasmata; and this is said to be especially the case when the animal food is taken " in the middle of the day, or frequently in one day." On examining Niebuhr's narrative, says Dr. Macculloch, " it is most apparent that the deaths of his companions were the consequences of gross feeding." " On this question," says the same writer, "there can perhaps be no better evidence than the opinions and practices of the intertropical nations themselves, among the mass of whom this subject seems well understood; while in many countries it is a caution actually often given to Europeans by the natives, though most generally neglected by them. It is, probably, from long experience, in some measure of its advantages, as well as from more obvious causes, that a vegetable Journal de Physiologie, Janvier, 1823. MIASMATA. 65 diet is so general throughout the aborigines of the torrid climates; while it is doubtless from principle, also, that among the people of Africa, to the northward, at least, the sole or the principal meal is supper." The class of diseases produced by koino-miasmata, if we take into view their various modifications, is by no means limited in its range. The most simple form of disease arising from this cause is the inter- mittent fever. In proportion as this febrific effluvium increases in potency, so does it produce fevers of a higher and more violent grade. The range of activity of this miasma extends from the simple tertian of the temperate latitudes to the malignant and fatal plague of the East, or the scarcely less fatal bilious fever of Batavia. Besides general fevers—assuming an endless diversity of character in different seasons and climates, koino-miasmata produce, also, vari- ous other affections, both local and general. Dysentery, cholera, and diarrhoea, are enumerated among the maladies produced by malaria. It may be doubted, however, whether miasma, by itself, without the co-operation of other causes, has any particular tendency to excite those affections. I apprehend, that in many instances occurring in malarious districts, as elsewhere, atmospheric vicissitudes, or cold, exerts no small degree of influence in determining the disease upon the alimentary canal. During the autumn of 1814, one-fourth, per- haps, of the men of four regiments encamped near Baltimore, were affected with intermitting and remitting fever in the month of Sep- tember. The weather was remarkably warm, equable and dry. The months of October and November, however, were rainy, extremely variable in temperature, and the majority of the men, who were pre- viously lodged in covered rope-walks and houses, were now encamped in tents. A week after the rainy and cold weather set in, dysentery and diarrhoea began to appear abundantly, and in the course of three weeks more, there were but very few cases of intermitting or remitting fever, but more than eight hundred cases of dysentery. Neverthe- less, the capability of miasmata of producing these forms of intestinal disease by its own unaided powers, is not to be questioned, although it is, I think, equally evident, that the co-operation of sudden changes of atmospheric temperature, or cold, is especially calculated to enhance the tendency of the miasmata to occasion these diseases. From these remarks, cholera ought to be excepted, for the cholera of India, at least, is most undoubtedly the product of a miasmatic agent. Dr. Macculloch mentions tic douloureux as a common consequence of the influence of miasmata—more especially in Italy; and the occurrence of periodical hemicrania, from this cause, is by no means unfrequent even in our own climates. In truth, there is scarcely a malady that may not be produced or simulated by the operation of malaria on the human system. The period which intervenes between the reception of koino-mias- ma and the first manifestation of its influence on the human body, is extremely various. Of many persons exposed to it at the same time, some may be immediately affected, others in a few days, some VOL. I.—5 66 MIASMATA. not until several weeks have passed, whilst others may remain free from its effects a still longer time. As the powers of koino-miasmata most probably vary considera- bly in different countries and localities, it may be inferred, as has al- ready been observed, that the fevers which they produce are impressed with a corresponding diversity in their character; and observation would seem to confirm this inference. Dr. Smith thinks, that what- ever external or general diversities may occur in fevers produced by this miasma, " their pathology or essential nature is everywhere the same." This is highly probable ; for the diversities in question would seem to depend more on the mere grade of violence, local affections, and general course of these fevers, than on any radical difference in their essential pathological conditions. Upon this point, however, it becomes us to speak with diffidence, as this question cannot be solved by mere closet inferences and reasonings, but by close observation and careful experience, in relation to these fevers as they occur in various countries, climates, and localities. v How far a mixture, or the combined agency of koino and idio- miasmata, may operate in producing novel or anomalous varieties of fever, it is impossible to say; but that such a combination does sometimes occur, and give rise to fevers of a peculiar or mixed cha- racter, will scarcely be doubted by any one who has given due atten- tion to this interesting subject. Professor Smith, to whose work I have already so frequently referred, has given this subject a compre- hensive and minute consideration, and to whom, indeed, the credit is due for introducing this interesting point of etiology to the notice of the profession. " Let us suppose," says Dr. Smith, " the circumstances in which typhus originates, to occur in summer, such as the crowding of individuals into small apartments, badly ventilated, and rendered offensive by personal and domestic filth. These causes would obvi- ously produce typhus in its ordinary form. But suppose there exist at the same time, those exhalations which occasion plague and yellow fever, or intermittent and remittent fevers. Under such^circumstances, we should not expect to see any one of those diseases fully and dis- tinctly formed, but a disease of a novel or modified character." There exists no doubt in my mind, of the correctness of Dr. Smith's obser- vation, that the late Bancker Street fever in New York, as well as the peculiar fever which prevailed among the blacks in this city, a few years ago, was engendered by the united influence of these two mias- mal poisons. I once had a striking illustration of the anomalous and fatal character which the united action of koino and idio-miasmata is apt to impart to fever. During the fall of 1814, while attending in the capacity of regimental surgeon, in the encampment at Balti- more, ten men affected with mild remitting fever were lodged in a room of confined dimensions, and as the weather was cold the room was kept pretty warm by fire, and the doors and windows as little opened as was admissible. The adjoining room was exceedingly crowded with invalids, and but little attention paid to cleanliness and ventilation. In a short time several cases of fatal typhus occurred in this room. Soon after this, the patients who were affected with inter MIASMATA. 67 mitting fever in the next room, manifested new and more alarming symptoms; blood began to ooze from their gums; extreme tender- ness of the epigastrium occurred ; the intellect was but little disturbed; the eyes were dull, watery and staring; the temperature of the skin and the pulse nearly natural; the animal powers so little prostrated, that one of the men died a few minutes after he had been sitting up with his back leaned against the wall of the room. They were all immediately removed to the Baltimore Hospital, and all except one died in a few days. There can be no doubt that this peculiar modi- fication of febrile disease was the result of the impressions of idio- miasmata (engendered in the house), made on systems already under the morbific influence of koino-miasmata* * A considerable effort has of late been made to destroy the doctrine of miasma. Dr. Willis, in his treatise on the Pathology of Fever, totally denies the existence of miasma, and inscribes all its imaginary influences to moist warm air. He advances many arguments in favour of this idea, and quotes the observation of Fourcault, that a healthy animal will soon die if its body be covered with an impervious glaze. " Becquerel and Breschet, repeating the experiment of Fourcault, discovered that the extinction of life under such circumstances was accompanied by a signal fall of temperature; the animal whose body was endued with an impervious glaze, began to lose heat on the instant, and the loss never ceased till life had fled.'* The function of the skin is intimately connected with vital manifestations —and Dr. Willis conceives that this explains why such serious consequences should follow its derangements. " In a hot, dry atmosphere animals perish from the effects of excitement; in a warm, moist air of a temperature no higher than that of their own bodies, they die as they do when covered with an impervious glaze—the conditions requisite to the access of oxidized plasma, and the removal of deoxidized plasma are wanting, and life ceases as a matter of course.'"' The reviewers, who show the greatest deference to the views of Dr. Willis, at- tribute much importance to the fact that the dew-point in warm and moist situations is very little below the temperature of the atmosphere; and also to the new ob- servation of Fourcault, that albuminous urine is produced by covering an animal with glaze. Notwithstanding the ingenuity of these ideas, and the importance of these facts, it will be found very difficult to overcome the weight of evidence brought forward in the preceding chapter to prove the existence of miasma from the influence of winds, situation, atmospheric vicissitudes, &c. This theory of Dr. Willis is, moreover, very deficient in the way of accounting for the varieties of such fevers as are usually attributed to the different forms of marsh effluvia. How can a single cause like " warm and moist air," produce a quotidian in one place, a tertian in another, a bilious remittent in others—with all the various epidemic and endemic complications of them that are so constantly remarked by authors and practitioners? How can a mere exposure to such a condition of the air produce a predisposition to feArer which is frequently not developed until the lapse of many weeks? There is no validity in the argument that miasm does not exist, because we cannot analyze it by chemical reagents. We do not doubt the existence of the contagious cause of small-pox, although no chemistry can appreciate it.—(Mc.) 68 CONTAGION. Sect. V.— Of Contagion. By a contagion is understood a deleterious agent secreted by the animal body in a state of disease, which, when brought to act on a healthy individual, will produce a disease specifically similar to the one from which it derives its origin. Contagions occur under two distinct forms, and may therefore be divided into two varieties : viz. 1. Those which consist of a palpable matter or virus ; and, 2. Those which consist of an imperceptible effluvium. The chrome conta- gious maladies are propagated exclusively by a palpable virus, and consequently always by actual contact. Those acute contagious dis- eases which are not attended by a specific local affection, or an exan- theme, are, on the other hand, exclusively propagated by a morbific contagious effluvium, and by consequence, solely through the medium of the atmosphere. Those acute diseases, which are essentially con- nected with a specific local affection, or an exantheme, are commu- nicated both by a palpable virus, and by an imperceptible effluvium, and consequently both by actual contact and through the medium of the atmosphere. We perceive, therefore, that of the extremes of a purely local, and a purely general malady, there is, on the one hand, communication of the disease solely' by a palpable matter, and, on the other, by effluvia only ; and that where the local and the general affections meet in the same disease, as essential concomitants, (in the exanthemata,) there the two modes of propagation also obtain.* It must be observed, however, that though in a practical point of view we may properly adopt these distinctions between contagions communicated by contact and through the medium of the atmo- sphere, yet, in reality, an actual contact must, necessarily, always occur between the contagion and the individual, before it can possibly produce disease, whether the contagion be a palpable matter, or an imperceptible miasm. The only material difference consists in the mode in which this contact is effected. One of the most remarkable peculiarities of contagious diseases, is their inherent and undeviating tendency to preserve their essential individuality, under whatever circumstances of age, sex, constitution, temperament, modes of living, climate, and place, they may occur. Thus, the small-pox of the present day differs in no essential circum- stance from the same disease as it was observed and described by Rhazes more than eight centuries ago ; and the itch has changed in nothing since the time of Galen. Any certain contagion can, so far as we know, produce only one disease ; and if the system has become insusceptible of such disease, its peculiar cause is no longer a morbific agent in relation to that system. The laws of the acute contagious diseases differ entirely from those * This arrangement is adopted from Dr. Hosack's very lucid classification of contagions and their peculiar diseases. There is no writer of the present day whose views upon the character and arrangement of this class of maladies de- serve higher respect and attention than those which have been promulgated by Dr. Hosack. CONTAGION. 69 which govern the rise, progress and declension of the chronic conta- gious affections. The former observe the utmost regularity in all these respects. The rise, advancement and decline, in short, the whole series of essential phenomena, are governed by laws as steadfast as those which regulate the motions of the planets. The latter class of diseases, on the contrary, are extremely irregular in their course, having no definite period of duration, nor established order and dura- tion of the successive phenomena of their course. The power which the acute contagious diseases have of destroying the susceptibility of the human system, to the subsequent influence of their specific causes, constitutes one of the most remarkable and mysterious characteristics of this class of maladies. In this respect, they differ as far from the chronic affections of this kind, as they do from the febrile diseases produced by general or non-contagious causes. In consequence of this law of acute contagious diseases, no malady of this kind can ever relapse during the period of conva- lescence. Considerable diversity of sentiment has been expressed in relation to the distance to which contagious miasmata may be dispersed from their source, in a state of sufficient activity to generate disease. That their sphere of activity is very limited, however, has been abundantly demonstrated, both by direct experiment and observation. The ex- periments of Dr. 0. Ryan, professor of physic in the college of Lyons, prove that the contagious miasm of small-pox does not extend more than a few feet beyond its source.* The most malignant contagions are rendered inert and harmless by being diffused in the atmosphere, and even by diffusion in the air of a well-ventilated apartment. Ven- tilation diminishes the activity of contagious effluvia simply by diffus- ing the miasm in a large portion of atmospheric air, in consequence of which those who become exposed to it, receive it in weak and inefficient doses. Contagions are perpetuated and conveyed to great distances from their source, by being absorbed by, and attached to, various sub- stances, such as clothing, furniture, bedding, &c, with which they are often transported even across the ocean. Animal substances, such as wool, hair, and articles manufactured from them are said to retain contagious matter with the greatest tenacity. The more the sub- stances which have become saturated with contagion are kept from the access of the open air, the more virulent and active will be its powers when it is brought to act upon the human system. Thus articles of clothing, after having been impregnated with contagious virus, will retain the power of infecting much longer, and in much greater intensity, if they are kept confined in close rooms, or locked up in chests or closets, than when they are freely exposed to the open air. It is by articles of this kind, locked up in trunks, that the small-pox, and other contagious maladies, have been conveyed to distant parts of the world in ships, although no person on board may have been sick with the disease during the voyage. The articles which are thus * Rees's Cyclopaedia; art. Contagion. 70 CONTAGION. imbued with contagious virus, are called fomiles. It was the op of Cullen, that contagions are more powerful when they_ are mus lodged in fomites,than when they arise immediately from the human body, or when in a separate state. The same opinion is expressed by Dr. Lind. . , The influence which peculiar atmospheric constitutions have on the activity of contagions, and on their tendency to dissemination, is a subject as interesting as it is inscrutable. The most careless observa- tion is sufficient to convince any one, that there exists in the varying constitutional, or perhaps accidental conditions of the atmosphere, a powerful modifying principle in relation to the powers of contagious agents. At times, it woulcLseem impossible for a contagious disease to extend the sphere of its ravages; for, although sporadic cases may occur here and there, yet no neglect in relation to proper seclusion will enable the disease to assume an epidemic or endemic character. During other periods, on the contrary, the accidental importation of fomites, or the occurrence of a case of contagious disease, acts like a spark of fire thrown among combustible materials, and speedily spreads disease extensively among the people. The same powerful atmospheric influence shows itself in the diversity of character, in relation to the grade of violence, malignity, and general diathesis, which the same malady is observed to assume at different periods of its prevalence. That these things depend on some modifying agency of the atmosphere, there can exist but little doubt. What this condition of the atmosphere consists in, it seems impossible to ascertain; it is probable, however, that it has no immediate connection with either the temperature or the hygrometrical state of the air; for with the ex- ception of typhus, which is manifestly favoured by cold weather, the contagious diseases of every kind prevail equally during the heat of the summer and the cold of the winter. The mode in which conta- gions are either favoured or retarded in their progress, by atmospheric constitutions, consists, probably, not in any influence which they may exert immediately on the powers of the contagion, but rather, perhaps, in their tendency to modify the human constitution, so as at one time to render it peculiarly susceptible of the influence of the contagion, and at another to diminish, or for a time to annul, the natural predis- position to its operation. Of the primary source of contagion we know but very little. It is probable that each contagious disease was at first developed, independent of contagion, by the accidental concurrence of various circumstances, which, in the infinite series of such contingencies, may not again occur for many centuries. That a disease may be originated by the concurrence of general causes, without the agency of a contagion, and which may afterwards communicate itself to others, by a specific virus of its own elaboration, we have a familiar example both in typhus fever and in itch. There is reason to believe, indeed, that various contagions have been thus produced, which have long since passed away from the face of the earth;* and it is not an * The sudor Anglkanus, so accurately described by Caius, appears to have been CONTAGION. 71 idle conjecture to say, that new contagions may hereafter arise which, after having exhausted their power on mankind, may again disappear for ever, or until a similar concurrence of causes, which at first evolved the contagion, again occurs. It is an interesting fact, that contagious diseases sometimes origi- nate in the lower orders of animals, and are afterwards communicated to the human species. Hydrophobia and the vaccine disease are familiar examples of this kind. Professor Remur has published some observations which go to show that other diseases, such as the virulent Coryza of horses, the plica of long-haired animals, and the gangrenous inflammation of the spleen, which occurs in cows, may be communicated by immediate contact to man. The following rules have been recommended for preventing the spread of contagious maladies to those who are obliged to approach patients labouring under diseases of this kind (Haygarth). 1. "The chamber in which the patient lies must be kept clean and freely ventilated. No bed curtains must be allowed to be drawn around the patient." 2. " Dirty clothes, utensils, &c, should be often changed, and im- mediately immersed in cold water; and washed clean when taken out." 3. "The discharges from the patient must be instantly removed; and the floor around the patient should be rubbed clean once a day with a wet cloth." 4. " Avoid the current of the patient's breath, as well as the efflu- via which ascend from his body, and from the evacuations " 5. " Visitors ought not to go into the patient's chamber with an empty stomach; and, in doubtful circumstances, on coming out they should blow from the nose and spit from the mouth any contagious poison which may adhere to these passages." Although it is quite certain that contagions will adhere to and imbue various substances, especially clothing, so as afterwards to reproduce the same disease, at a distance from their source, and often a long time after they had been generated ; yet it seems to be well ascertained, that such substances (clothing) can rarely be so greatly imbued with contagion by a slight and transient exposure to the poison, as to be capable, afterwards, of producing disease in the healthy. The clothes of transient visitors, for instance, will scarcely ever imbibe sufficient contagion to communicate the disease to others. Dr. Clark affirms," that in eighteen years of medical practice, he never communicated the contagion of small-pox nor of scarlet fever to any one, although he had frequently, on the same day, visited many patients sick with these diseases, and in their most malignant forms." a highly contagious disease. It visited England five times in the period of seven years, and swept off a vast number of victims by its fatal violence. In many in- stances, those who were affected with it died within an hour, and few who sank under its malignity suffered longer than four or five hours. It has not been known to occur for several eenturies past, its contagion having long since become wholly extinct. 12 CONTAGION. Mere ventilation is inadequate to destroy the contagion deposited in fomites. To effect this important object, a great variety of means, such as exposing them to various vapours and fumes, have been de- vised. Without enumerating the different disinfecting agents which have been successively brought forward and again rejected, it will be sufficient to mention those which experience has shown to possess active powers in this respect, and which are now relied on as un- questionable disinfecting agents. The nitrous acid vapours have been much employed for disinfecting ships and houses in which con- tagion has been found to exist. Such was the evidence brought for- ward of the efficacy of the nitrous acid fumes in purifying infected places and fomites, that the British parliament voted a national donation of five thousand pounds to Dr. Carmichael Smith for the discovery. This vapour is readily obtained by mixing with powdered nitre, in a cup, a little of sulphuric acid, and applying gentle heat with a lamp. At present, however, chlorine, and the chlorides of lime and soda, are regarded as decidedly the best disinfecting agents we possess. M. Labarraque's disinfecting soda liquidise compound of soda and chlorine, and its efficacy in destroying infectious matter has been conclusively demonstrated. " It is now much used in removing the offensive odour arising from drains, sewers, or all kinds of animal matter in a state of putrefaction. Bodies disinterred for the purpose of judicial inquiry, or parts of the body advanced in putrefaction, may, by its means be rendered fit for examination ; and it is employed in surgical practice for destroying the fetor of malignant ulcers. Clothes worn by persons during pestilential diseases, are disinfected by being washed with this compound. It is also used in fumigating the cham- bers of the sick, for the disengagement of the chlorine is so gradual, that it does not prove injurious or annoying to the patient. In all these instances chlorine appears actually to decompose the noxious exhalations by uniting with the elements of which they consist, and especially with hydrogen." " Pure chloride of soda is easily prepared by transmitting to satura- tion a current of chlorine gas into a cold and rather dilute solution of caustic soda. In preparing the disinfecting liquid of Labarraque, it is necessary to be exact in the proportion of the ingredients employed. The quantity used by Mr. Faraday, founded on the directions of Labar- raque, are as follows: Dissolve 2800 grains of crystallized carbonate of soda in 1-28 pints of water, and through the solution contained in a Wolf's apparatus, transmit the chlorine evolved from a mixture of 967 grains of sea-salt and 750 grains of peroxide of manganese when acted on by 967 grains of sulphuric acid diluted with 750 grains of water."* s Turner's Elements of Chemistry. GENERAL COURSE, &C, OF FEVER. 73 CHAPTER III. OF THE GENERAL COURSE, TYPE, AND STAGES OF FEVER. The series of phenomena which intervene between the commence- ment of a fever, and its termination in convalescence, constitutes what is technically called its course. The course of a fever is either inter- milting, remitting, or continued, according as its phenomena inter- mit, or remit, or are continuous. The series of phenomena which constitute the course of a fever, may be divided into six periods or stages: viz., the forming, the cold, the hot, the critical, the declining, and the convalescing periods. It should be observed, however, that these stages are not always distinctly marked, in violent and continuous forms of fever, although very few fevers occur in which the primary stage of oppression, the ' stage of excitement, and the period of declension, may not be distinctly observed. The febrile paroxysm of an intermitting fever offers the most distinct exemplification of the successive changes or stages which occur in the course of a fever. 1. The forming stage—the stadium prodromorum includes the period which intervenes between the first impressions of the febrific cause, and the actual commencement of the febrile phenomena. This period is characterized by a variety of feelings or sensations, which, though manifesting a deviation from the healthy condition of the sys- tem, do not constitute any definite state of disease. These constitute the premonitory symptoms. Their duration is very various; and in some instances, though very rarely, they are entirely absent—the disease making its attack at once, without any previous manifestations of its approach. This is most apt to occur in fevers of very vigorous reaction, and in such as are of a malignant character. The longer or shorter duration of the premonitory stage depends, however, probably as much on the different powers of vital resistance as on the differ- ence in the degree of concentration or activity of the remote febrific cause. The whole train of premonitory symptoms may be regarded as the result of the struggle between the vital powers and the febrific cause. If the cause be feeble, and the vital resistance great, its first impressions may give rise to some unusual or unpleasant sensations, until the system finally triumphs over its influence, and disease be obviated. When the relative powers of the cause and the vital re- sistance are more nearly balanced, the struggle between them may be prolonged, until the latter yield and disease be developed; and where the system resists feebly, whilst the febrific cause acts with energy, the contest will probably be short, and the fever occur suddenly, with violent symptoms. There exists, nevertheless, in almost every febrific 74 GENERAL COURSE, &C, OF FEVER. cause, a natural tendency to produce some peculiar premonitory symp- toms, although the general and most conspicuous of these phenomena are pretty nearly the same in almost every form of febrile disease. In general, those fevers which are apt to run through a protracted course, have a much longer train of premonitory symptoms than such as are violent and of short duration. Thus, the premonitory period is almost uniformly much more protracted in typhus and typhoid than in the synochal fevers. The following are among the most common symptoms of this initial period of febrile affections; loss of appetite ; disturbed sleep; yawning, stretching, lassitude, wandering pains in the limbs and back; an unpleasant sensation in the stomach; a harsh and dry skin, irregularity of the bowels; a general feeling of mal-aise; nausea; eructations; interruptions of the ordinary habits and appetites; fret- fulness; discontent; slight headache; slight creeping sensations of cold; the drying up of old sores ; tremors of the extremities; changed expression of the countenance; giddiness; and perhaps some other slight deviations from a state of perfect health, or the ordinary habits and feelings of the individual. If we examine the symptoms of this stage in the usual order in which they «ccur, we will perceive that the nervous system is the first that suffers; this is manifested by the lassitude, languor and slight transient pains, which usher in this stage. Next, the digestive organs are brought into a state of slight suffering; and finally the skin. The heart and arteries appear to be the last organs which are brought into morbid action in the development of fever. 2. The cold stage—Nearly all fevers commence with more or less sensation of chilliness. The feeling of cold is not always at- tended with an actual subduction of sensible temperature. In some instances the skin of the patient feels warm to the touch, whilst he is shivering under the severest sensations of cold. It is manifest, therefore, that in such cases, the feeling of cold depends in reality on an altered or morbid condition of the sensibility of the skin, in conse- quence of which its power of perceiving (if I may use the expression) the ordinary degree of animal temperature is diminished. In most instances of febrile chills, however, there occurs an actual reduction of the temperature of the surface, especially of the hands and feet.— Not unfrequently these parts feel quite cold to the touch of a healthy person, whilst the surface of the trunk and the forehead are of the natural temperature, and sometimes apparently even higher; al- though the sensation of chilliness experienced by the patient will be diffused throughout his whole system. The chills are attended with a pale, contracted, and dry state of the surface; the volume of the body is diminished; the respiration confined, irregular, anxious, and oppressed, attended frequently with a short dry cou^h- the head feels confused; the tongue is dry, attended sometimes with great thirst; the pulse becomes extremely small, frequent and feeble; nausea often occurs, and sometimes vomiting. The sense of chilli- ness is usually diffused over the whole body; though in some in- stances, it is partial, and occasionally, limited to a small part of the GENERAL COURSE, &C, OF FEVER. 75 body. In general, the more violent the chills are, the more vigorous will be the subsequent arterial reaction. As the cold stage gradually subsides, the arterial reaction regularly rises, until chilliness has wholly gone off, and the disease has entered into the— 3. Third, or hot stage.—This stage is characterized by what may be termed the essential phenomena of fever: viz., augmented heat, and a return of the natural fullness and colour of the surface ; flushed countenance ; a full, quick, frequent and vigorous, or a small, tense, quick and frequent pulse ; throbbing pain in the head : eyes promi- nent and sensible to the light; a dry and hot skin ; urine scanty and high-coloured ; continued wakefulness, &c. These symptoms, with more or less intensity, continue for a longer or shorter period, until the acme of the febrile condition has arrived at the period when — 4. Crisis supervenes. By crisis is understood, in the most gene- ral acceptation of the term, that period in the course of a fever at which it has arrived at its highest point, and a determination either to a fatal or favourable issue takes place ; and by which, therefore, the fate of the patient is determined. The period during which this decision occurs, is necessarily always short; and is almost universally attended with some evacuation. The most common critical evacua- tion of a simple febrile paroxysm, consists of a very greatly increased flow of perspiration, and hence the subsequent period during which this evacuation is continued, is called the sweating stage, but which I would call— 5. The stage of declension—stadium decrementi morbi.—This stage may be considered as commencing immediately after the favour- able crisis has taken place. In the rapid, continued fevers, and in a single paroxysm of an intermittent, one crisis only occurs ; but in by far the greater number of protracted, and especially in remitting fevers, the crises continue to recur through the whole period of de- clension at every tertian exacerbation, until the disease is finally subdued. The duration of this stage is extremely various. In gene- ral, the period of declension will be pretty nearly in proportion to the period occupied in the progress of the fever to its acme. The space of time which is occupied by one paroxysm of a fever and its succeeding intermission, or which intervenes between the regular periodical exacerbations of fever not paroxysmal, is called the revolution of a fever. The revolutions of fevers are various in point of duration ; some fevers completing theirs in twenty-four hours, others in forty-eight, whilst others require seventy-two, and some even ninety-six hours. The form which a fever assumes, in this respect, is called its type; so that a fever which occupies twen- ty-four hours from the commencement of one paroxysm to another, is said to be of the quotidian type ; whilst one which revolves every forty-eight hours, is of the tertian type ; and when this period is ex- tended to seventy-two hours, the fever is of the quartan type; and a period of ninety-six hours constitutes the quintan type. The quotidian, the tertian and the quartan types constitute the three principal and primary types of fevers; all of which are, however, subject to modifications which may readily mislead the careless ob- 76 GENERAL COURSE, &C, OF FEVER. server, so as to confound them, or mistake one for the other, especially the quotidian and the tertian. , It has been observed, that in fevers of the quotidian type, the pa- roxysms generally come on in the morning—a circumstance, which has been almost invariably verified in my own experience, and which is, indeed, so constant, that Cullen was induced to notice it in his defi- nition of a quotidian. Tertians commonly come on towards noon; but they are much less regular, in this respect, than fevers of the pre- ceding type. Two simple tertians sometimes go on cotemporaneously in the same patient; so that, instead of the paroxysms recurring only every other day, they occur daily, as in a quotidian. These cases are called double tertians, and are distinguished from quotidians by the paroxysms of the alternate days being similar in relation to the pre- cise time of their occurrence, grade of violence, duration, and other circumstances. Thus the paroxysms on the odd days will perhaps recur at 9 o'clock in the forenoon, whilst those which happen on the even days will come on at 2 or 3 o'clock in the afternoon, so that, although each day has its paroxysms, the fever cannot be properly considered as a quotidian, but the cotemporaneous progress of two simple tertians, the one having commenced a day sooner than the other. Fevers, however, rarely assume the double tertian type from their commencement. They usually begin and continue for some time in the simple tertian type—the duplication occurring afterwards; and when the type thus becomes doubled, the new or accessory pa- roxysms are generally considerably milder than those of the original or simple tertian. It is asserted, that a double tertian seldom termi- nates without first assuming the single tertian type—the accessory or weaker paroxysm disappearing first.* There are other varieties of double tertians, mentioned by the older writers, such as the tertiana duplicata, in which two paroxysms occur every second day, and none on the intervening one ; the hxmi- tritseus of the ancients, in which a paroxysm occurs daily, the inter- missions or remissions between the first and second, the third and fourth, being much more prolonged than those which occur between the second and third, the fourth and fifth, &c. Authors also mention a triple tertian—tertiana triplex. The quartan type, also, has been known to assume similar modifi- cations. Double and triple quartans are mentioned in the books; as well as other anomalous varieties of this affection. Before I proceed to the consideration of the particular forms of fever, it will be proper to say something concerning crisis or criti- cal days—a subject which, though but little regarded at the present day, appears to me entirely worthy of attention. It may, I think, be assumed as a safe principle, that doctrines or sentiment's concerning facts which are objects of mere observation and experience, cannot be wholly erroneous or illusory, after having obtained the entire con- fidence, through a series of more than twenty centuries of a vast number of as accurate and devoted observers of nature as'have ever * Richter's Specielle Therapie, vol. i. GENERAL COURSE, &C, OF FEVER. 77 adorned our profession. Without professing a belief in the correct- ness of the doctrine of crisis as it was taught by the ancients, and by many of the moderns, we may yet admit, on good grounds, it is con- ceived, that there exists a natural tendency in the operations of the animal economy, whether in a state of health or disease, to certain periodical fluctuations, which, under particular circumstances, mani- fest themselves in a way sufficiently conspicuous to exhibit an obvious revolution in the increase and declension of the morbid actions of the animal system. It was early observed, that there are certain regular periods in the course of many febrile affections, at which prominent changes are wont to occur, preceded generally by a mani- fest aggravation of the symptoms, and followed or attended by certain evacuations. These evacuations, from their being almost always followed by an obvious abatement in the symptoms, were called criti- cal, and were thought to consist of noxious or febrific matters, thus thrust out of the system by the sanative powers of nature. Fever was supposed to be nothing else than an effort of nature to prepare and cast out of the system the morbific materials which disturbed the regular actions of the animal economy, and that the amendment which ensued was the immediate consequence of such eliminations of morbific matter. At the present day it is, however, more correctly maintained that these critical discharges are the effects, and not the causes of the melioration which occurs about the periods at which they take place; and that they are to be viewed rather as the first manifestations of a favourable change in the condition of the system than as the immediate causes of such a change. That this is the cor- rect view in relation to the nature of such discharges, there can, in- deed, exist no doubt; but this view of the subject does not deprive it of its importance, and directs our attention rather to the periodical exacerbations and inherent tendencies in these maladies to terminate their course at one period in preference to another, than merely to the evacuations which are apt to supervene at such times. In no forms of fever, perhaps, are these tendencies to terminate at a certain fixed period more frequently manifested than in intermittents. There appears, in these fevers, a tendency to a septenary revolution, which I have often seen verified in the most unequivocal manner. If an ague of the quotidian type be suffered to run on until it terminates spontaneously, the termination will almost universally occur, if it occur at all, either after the seventh, fourteenth, or twenty-first parox- ysms ; and I have repeatedly found, that febrifuge remedies, exhibited immediately after these septenary periods, will arrest it with more certainty, and with much less liability to relapse, than when employed during any of the intervening intermissions. From the same inhe- rent tendency, the relapses which are so common in this disease will, in a vast majority of instances, occur about the septenary periods from the time of the last paroxysm, and most commonly about the eighth or fourteenth, and sometimes for several periods about the twentieth day—(Jackson,* Sprengle.t) * On the Diseases of Jamaica. t Handbuch der Pathologie, Band. ii. p. 171. 78 GENERAL COURSE, &.C., OF FEVER. Observation has shown, that the crises of fevers happen almost uniformly on the odd days, reckoning from the commencement ot tne malady. According to the observations of Hippocrates, tne crises occur in conformity to the tertian type, until the nith crisis, or tne eleventh day of the fever, after which they observe the quartan type, occurring only every fourth day. It must be observed, however, that these evacuations do not occur exclusively on the days just indicated, for they are sometimes, though rarely, found to happen on the inter- vening days. Galen supposed, that when the crisis falls on any other than a critical day, the fever has been diverted from its natural tend- ency by the accidental occurrence of irritation in some part of the system. Galen divided the critical days into the perfect, the secondary, and the intercurrent. The perfect are those which happen on the seventh, fourteenth, twenty-first, and twenty-eighth days. The second- ary, or less perfect, occur on the intermediate day between each perfect or septenary crisis—namely, the fourth, eleventh, eighteenth, twenty-fifth, &c, days. If, for example, it was observed that a slight deposit in the urine, or a moderate flow of sweat took place on the eleventh day, it was regarded as an indication of a more perfect crisis on the fourteenth day. The intercurrent crises occur on the remaining odd days—that is, on the fifth, ninth, thirteenth, &c. Such are the prin- cipal points in the doctrine of crisis, as it was taught by the ancients, and more especially by Hippocrates, and his commentator Galen. No one at the present day, however, pretends to have observed the many minute distinctions and phenomena which are embraced in the ancient doctrine on this subject; indeed, there are very few who regard it as at all worth any attention; and the profession seem long sinc& to have thrown it into the common mass of error and miscon- ception, which has been formed out of the wrecks of former systems and doctrines. However antiquated it may appear, at the present advanced stage of our science, to profess some faith in the general correctness of this doctrine, I cannot, at the risk even of being set down as a cherisher of obsolete and exploded sentiments, divest my- self of the conviction, that among much that is erroneous and absurd in this doctrine, there are important and fundamental truths which ought not to be carelessly rejected. In order to understand the nature of crisis, every fever must be considered as having a tendency to some one of the principal types mentioned above. A simple tertian intermittent may be regarded as the elementary type of fever. In fevers of this type, an exacer- bation or paroxysm, and a crisis, will occur on every odd day; and if we consider a continued fever as made up of tertian paroxysms pro- longed and running into each other, or as possessing a natural, though countervailed tendency to the elementary or tertian type, there will, in like manner, occur more or less considerable tertian exacerbations, with their accompanying discharges. From what has already been said concerning the manifest septenary movements of intermittents,the tendency of continued fevers to terminate on the fourteenth or twenty- first days, which can scarcely be denied, would seem to be in conform- GENERAL COURSE, &C, OF FEVER. 79 ity with an original law of the animal economy, under a state of febrile excitement. The evacuations which usually accompany the crisis of fever are, —1. haemorrhages; 2. a flow of sweat; 3. an increase or changed character of urine ; and 4. diarrhoea. Critical haemorrhages are gene- rally attended with an increased action of the heart and arteries, and often with a manifest determination to, and congestion in, the part from which the discharge occurs. They must be regarded as mere manifestations of a previous change in the system, and hence this critical kind of evacuation cannot be substituted by an artificial ab- straction of blood; since, although blood may be abstracted, the pecu- liar action of the solids, which constitutes the actual crisis or change to a favourable tendency, cannot be thus produced. Crisis, by haemorrhage, is generally confined to inflammatory fever; or, more correctly speaking, to fevers attended with an increased activity and action of the heart and arteries. Critical haemorrhages most conir monly proceed from the nose, and, according to the observations of many of the older writers, are frequently preceded by the dicrotus pulse, in which two distinct wave-like beats occur during each dias- tole of the artery. Immediately before the irruption of the blood the carotids beat strongly, the face becomes flushed, sparks appear before the eyes, the eyes are red and suffused with tears; and, in some in- stances, frequent sneezing, and a thin watery discharge from the nos- trils occur just before the haemorrhage appears. Critical sanguineous discharges have also been known to occur from the uterus, the rec- tum, and sometimes, though very rarely, from the stomach, and even from external parts. Crisis by an increased flow of perspiration is by no means uncom- mon. Catarrhal and rheumatic fevers are more apt to terminate by this mode of crisis than any other forms of febrile affection. This discharge is not, however, to be regarded as indicative of a favourable change in the malady, unless it be generally diffused over the whole surface, and especially, unless it be attended with a turbid slate of the urine, or a copious sediment in this latter evacuation. The sur- face should, moreover, be soft, and of a natural temperature—that is, not cold and clammy. Crisis by urine, independent of perspiration, is a very uncommon mode of termination in febrile complaints. A critical urine derives its favourable character not so much from the mere quantity of the evacuation, as from its appearances and the materials with which it is impregnated or mixed. For inspection, the urine which is evacuated at the termination of a paroxysm, or in the morning, ought to be chosen. In a truly critical urine there may be seen at first a cloud floating in the upper part of the vessel, then a globular body of mu- cus about the middle, and a sediment at the bottom.* So universal * Vogel Richter, Hufeland. I have frequently noticed these appearances in the urine, evacuated after a paroxysm of intermitting fever; and I am well satis- fied that it is a common occurrence in the urine discharged soon after fevers have commenced to decline. so GENERAL DIAGNOSIS. is the concurrence of a critical urine, and a general nioistureorthe skin, that these two evacuations may be considered as essenuauy connected. , tI..„. T A critical discharge from the bowels is less common than tnose i have already mentioned. It occurs most frequently in bilious levers, and in such febrile affections as are attended with some visceral dis- ease within the abdomen. These discharges do not however occur as the others do, in the acme or exacerbations of the fever, but during the periods of remission. They are generally very copious the signs of an approaching crisis by diarrhoea are a pecubar trembling ot the under lip ; stammering speech ; a full and wave-like pulse ; pain and rumbling noise in the bowels; discharge of wind; a moist tongue; itching in the nose; paucity of urine, &c. (Richter.) CHAPTER IV. ON GENERAL DIAGNOSIS. « Nothing so much distinguishes the experienced and truly well- qualified physician from the mere haphazard recipe-doctor, and rou- tinist, as the ability to estimate correctly the import of symptoms; to trace their various relations with each other, and to determine from them the seat, nature, and extent of maladies. The number of those who are remarkable for accuracy in diagnosis, is always very small; for eminent proficiency in this respect can be obtained only by persevering observation and study, aided by a minute and com- prehensive acquaintance with physiology and pathology. Diagnosis embraces a much wider range of inquiry than that which is presented by the actual phenomena of diseases. It is not alone from morbid symptoms that the intimate character and tendency of diseases can always be satisfactorily determined. Age, sex, moral and physical temperament, climate, occupation, habit of living, cor- poreal conformation, previous diseases, hereditary predisposition, and the character of the predisposing and exciting causes, often afford important aid in the formation of a correct diagnosis. In chronic diseases, especially, the light which may be obtained from circum- stances of this kind, is frequently of the utmost importance in this respect. The manner in which patients are examined, also, has a direct and important bearing on diagnosis. A confused, desultory, or imme- thodical mode of investigating the symptoms of diseases, and the various circumstances which may have contributed to determine their character, seldom leads to a clear and precise diagnosis. Indeed the manner in which a physician examines his patients affords no incon- siderable criterion for judging of his practical qualifications. Method GENERAL DIAGNOSIS. 81 regularity and deliberation, in this respect, are almost always asso- ciated with skill in diagnosis, and consequently in the treatment of diseases. The first objects which strike the attention of the physician, on ap- proaching a patient, are his countenance, attitude, motions and voice. It is natural, therefore, to commence the examination with these symp- toms. In many instances these external conditions of the patient afford very important information as to the nature and seat of mala- dies ; and in no case, perhaps, can they be entirely neglected without losing very useful suggestions in relation to the diagnosis. The countenance should be deliberately and closely examined, and its deviations from the healthy aspect and expression noticed. Many diseases are attended with expressions of countenance so peculiar and striking, that they may be at once recognized by the observant and experienced physician. The attitude, motions, and external condition of the patient's body, must, also, be particularly noticed. The degree of emaciation—the colour and condition of the skin, and the general physical habit and conformation, should be observed. The various regions of the body should be carefully examined, more especially in diseases of a chronic and obscure character. In some general maladies, such as scurvy, syphilis, scrofula, &c, the ecchymo- ses, glandular indurations, eruptions, blotches, exostoses, nodes, &c, afford important diagnostic evidence. Old cicatrices, too, merit par- ticular attention ; particularly when seated along the neck and in the groins. The former almost always indicate a scrofulous diathesis, whilst the latter afford good grounds for suspecting the existence of a syphilitic taint. The existing disease, for which the physician is called to prescribe, may have a very intimate connection with one or the other of these maladies or constitutional taints; and as patients are apt to neglect giving proper information on this subject, or even seek to conceal the fact of their having been affected with such a disease, these old marks or cicatrices are sometimes of essential ser- vice, to a full and satisfactory investigation of the case under exami- nation. Having attended to these external circumstances, the examination of the case must be pursued, by interrogating the patient. The man- ner in which the examination is conducted, is of great importance. A careless, irregular and hurried, or a peevish, fretful and impatient manner of examining, seldom fails to lessen the good will and confi- dence of the patient for his medical attendant; whilst a mild, deliberate, earnest and interested deportment, not only gains the patient's confi- dence and respect, but contributes very materially to a full develop- ment and correct understanding of the nature of the malady. The questions should always be proposed in terms perfectly intelligible to the patient; and when there is reason to doubt whether the interroga- tory has been correctly apprehended, it should be repeated in different terms. The employment of a pompous and technical phraseology, is more apt to excite the contempt and distrust of intelligent patients, than to draw forth correct and satisfactory responses. It is of considerable consequence, also, to follow a determined and vol. i.—6 S3 GENERAL DIAGNOSIS. regular order in the questions put to the patient. Without a proper attention to order or method in this respect, important questions are apt to be forgotten, and some which have already been proposed and answered, uselessly repeated. Although the interrogatories should be sufficiently numerous and varied to obtain a full view of the symp- toms and feelings of the patient, and of the circumstances which may have contributed to the development and modification of the disease, yet trivial and irrelevant questions should be avoided. The following order of inquiry appears to me the most natural and advantageous. 1. Ascertain the age, occupation and place of resi- dence of the patient. In many instances, indeed, these circumstances, more especially the last, can have no useful bearing on the diagnosis; but this is by no means always the case; for, in some cases, very important diagnostic and practical suggestions may be obtained from a careful consideration of these facts. 2. Inquire next, at what time the disease commenced; whether it came on gradually or suddenly; whether the existing symptoms differ from those which attended the disease at an earlier period; whether the progress of the complaint is continuous or paroxysmal, constant or occasional, uniform or attended with exacerbations and remissions; whether, in the course of the dis- ease, new symptoms have supervened, and former ones disappeared, and whether the permanent symptoms have increased much in vio- lence since the commencement of the complaint. Correct information in relation to these circumstances is often indispensable to a satisfactory diagnosis. " In many instances, indeed, the succession and general progress of the symptoms, afford more useful data for the formation of a correct diagnosis, than a consideration of the symptoms existing at the time of examination. Unfortunately, the majority of patients are incapable of giving a proper account of the early symptoms and progress of their maladies; and the physician is thus frequently de- prived of the light which a correct and circumstantial exposition of the preceding symptoms and course of the case might afford." 3. The patient should now be asked whether he experiences any pain, and if so, in what part of the body. He should be directed to place his hands on the region in which the pain is felt; for patients are apt to express themselves very vaguely and incorrectly in relation to the part in which the pain is seated. Thus, we are often told that pain is felt in the stomach, yet when the region is pointed out with the hand, it is, perhaps, found to be seated in the lower part of the abdomen, or within the chest. Inquiry must also be made whether the pain be acute or darting; dull and aching; stinging or burning, or throbbing; —whether it be deep seated or superficial, continuous or intermitting, wandering or fixed, transient or protracted; and, if intermitting or paroxysmal, whether its occurrence be periodical or at irregular and uncertain intervals. Pressure should be made on the part in which the pain is located, and its effects carefully noticed ; and it is particu- larly important to ascertain whether there is soreness or tenderness to pressure in certain organs or regions of the body, more especially in the various regions of the abdomen ; although the patient may not complain of any pain in these parts, when undisturbed by pressure. GENERAL DIAGNOSIS. 83 It will also be proper to ascertain whether the affected parts are swollen, discoloured, or in any other way changed from their normal or healthy appearance and conformation. 4. The state of the san-. guiferous system should next be inquired into. The pulse must be attentively and deliberately examined; and in doing this, attention must be paid to the circumstance, that the pulse of an infant, during the first three or four weeks after birth, beats between>120 and 130 strokes in a minute; and that its natural frequency undergoes a gra- dual reduction as age advances, until about the age of puberty, when it arrives at the standard of a healthy adult pulse, namely, from about 72 to 80 pulsations in a minute. It should be observed, too, that climate, the time of day, corporeal exertion, position of the body, and mental emotions or exercise, exert, often, a very material influ- ence on the state of the pulse. In the morning, whether in health or disease, the pulse is generally considerably slower and softer than after dinner or towards evening. In feeble and nervous individuals, we often find the pulse much more frequent when they are standing up, than when in a recumbent position. In this case, the muscular exer- tion required to maintain the erect posture operates on the circulation in the same way as exercise, and therefore accelerates the action of the heart and arteries. Nothing, however, is so apt to give rise to a wrong estimate of the state of the pulse, as that mental excitement and flurry which feeble and irritable patients are apt to experience on the entrance of the physician into the sick chamber. I have fre- quently found adifference of more than twenty pulsations in a minute, between an examination made immediately after entering the room, and a second one, some ten or fifteen minutes • afterwards. It is therefore an important rule, to delay examining the pulse, until the agitation of the patient's mind has subsided. By introducing the examination with some encouraging and cheering remarks, and pro- " ceeding in the order already mentioned, there can seldom be any risk of mistake, from this source, as to the actual state of the .pulse. In examining the pulse, the patient's arm should be held in a horizontal and semiflexed position. Two or three fingers must be applied to the artery, and the pressure gradually varied in force, in order to form a correct estimate of the degree of tension, vigour, hardness or com- pressibility of the pulse. Thirty or forty pulsations, at least, ought to be felt before the fingers are taken off. It is not uncommon in certain obscure cerebral affections, to find an intermission in the pulsations, at intervals of from ten to thirty and even a greater number of beats. A transient examination, may not only fail to detect such intermis- sions, but is in general, quite insufficient for obtaining a satisfactory view of the precise character of the pulse. All conversation should be forbidden, both on the part of the patient and the attendants. In certain affections, and when the system is under the influence of cer- tain remedial agents, (as digitalis,) it will be proper to examine the pulse in different positions of the patient's body; namely, in the re- cumbent, sitting and standing postures. This is particularly useful in certain organic affections of the heart. There is, perhaps no depart- ment of symptomatology in which a high degree of proficiency is 84 GENERAL DIAGNOSIS. so seldom met with among physicians, as that which relates to the morbid manifestations of the pulse. Many seem to think that the only modifications of the pulse, which are worthy of particular atten- tion, relate to its^ frequency, fulness, hardness, tension an^.r£§l^anty/ There are various other states of the pulse, however, which though not easily described, communicate to the experienced and diligent observer, definite and important views concerning the pathological conditions with which they are associated. The ancients, and even some of the moderns, undoubtedly carried their refinements and pre- tensions, in relation to this subject, to an absurd extent. It is not improbable, however, that among much useless rubbish, which in the progress of our science, has been swept away concerning the organic pulses, as they were called, some valuable facts and principles were included, which might be advantageously revived. Be this as it may, a faithful and continued attention to the morbid states of the pulse, with diligent and well directed efforts to obtain definite conceptions of its various modifications, and to associate them with their respective pathological conditions, will, in general, result in the acquirement of a precision and readiness of discrimination, and accuracy of diagnostic application, which few who have not made the pulse a particular object of study and observation can well conceive or credit. 5. Hav- ing ascertained the condition of the pulse, the attention should be particularly directed to the organ or part in which the primary or essential malady appears to be seated. Inquiry must next be directed to those structures or organs which are known to hold the most inti- mate sympathetic relations with the part or organs principally affected. Thus, if the patient complains of much pain, or of other unpleasant sensations in the head, after having obtained a circumstantial account of the cephalic symptoms, the examination should be directed to the state of the alimentary canal. Again, if there is a fixed pain in the lumbar region, the important question whether the pain be located in the kidneys, or in some neighbouring structure, may, in general, be readily settled, by attending to the condition of those organs with which the* kidneys sympathize most strongly ; namely, the stomach, the ureters, and the testes. If there is a retraction of the testes, pains shooting down along the ureters, with nausea and vomiting, the fact of its being a renal affection may be regarded as sufficiently as- certained. In the investigation of diseases, it should be recollected that the prominent and most annoying symptoms are by no means always located in the part where the primary and actual malady is seated. A slight inflammatory affection at the origin of a spinal nerve, not unfrequently manifests itself by severe and protracted pain in some remote part of the body; as in the chest, the abdomen, or the inferior extremities. When, therefore, a fixed pain is unattended with any other manifestations of disease in the part; when there is neither inflammation, nor soreness or tenderness to pressure, we may pre- sume, that the primary affection, upon which the disease depends, is located in some other part of the body; and on proper inquiry, it will perhaps be found to be seated at the spinal origin of these GENERAL DIAGNOSIS. 85 nerves, which are distributed to the structure in which the pain is felt. To ascertain whether this be the case, firm pressure must be made on each of the spinous processes of the vertebral column. If, in passing successively from one spinous process to another, the patient flinches and complains of pain in one or more vertebrae; it may be inferred that the source of the painful affection is probably seated at the root of the nerves which pass out from that part of the spine. Many diseases, which appear to be of a general character, con- sisting seemingly in mere functional derangement, are nevertheless intimately connected with obscure and frequently very serious local affections. The diagnosis, in such cases, is generally extremely difficult. In some instances, a probable opinion, as to the existence, seat and character of such obscure and local affections, can be formed only by taking into view the effects of certain remedies and the na- ture of the exciting causes, in connection with the actual symptoms and general progress of the malady. Inflammation of some portion of the mucous membrane of the alimentary canal, often attends general diseases with manifestations so slight and inconspicuous, as sometimes to escape the notice of even attentive observers. In rela- tion to the diagnosis on this point, especial attention must be paid, in the examination of the symptoms, to the appearance of the tongue ; the condition of the alvine evacuations; the effects of irritating in- gesta ; the effects of firm pressure on different parts of the abdomen, with regard to the sensations which it excites ; the state of the skin ; and if the malady is of a chronic character, the temper and condition of the mental faculties. It should be particularly noticed, whether the surface of the tongue be red, and of a granular or smooth appear- ance—whether irritating and solid ingesta give rise to pain and distress in the stomach, or tormina in the bowels; whether, pressure on any part of the abdomen gives rise to a pain or a feeling of sore- ness ; whether the skin in connection with these symptoms be dry, harsh, and contracted, and whether the temper is morose, gloomy, taciturn and irritable. The particular appellation of these pheno- mena will be fully illustrated in a subsequent part of this chapter. I proceed now to the consideration of the particular diagnostic signs as presented by the countenance, the attitude, the nervous system, the alimentary canal, the blood-vessels, the respiratory organs, the cuticular surface, the lymphatic system, and the secretions. 1. The countenance is variously and often strikingly changed by diseases, and affords in many instances, highly important diagnostic indications. Hippocrates strongly recommends the study and exam- ination of the countenance in disease. His attention, however, was directed principally to the prognostic signs, manifested by the coun- tenance, and the observations which he has left us, on this subject, are among his most valuable contributions to our science. In relation to diagnosis, however, we find but few observations in his writings, concerning the morbid expressions of the countenance. This point has been more particularly attended to in latter times; and although there is still much room for profitable inquiry, yet the facts and priii- 86 GENERAL DIAGNOSIS. ciples which have already been established, are sufficiently numerous and interesting, to show the importance, of attending to the counte- nance, as a source of valuable diagnostic information. M. Jadelot, physician to the Hbpital des Enfans Trouvfes, has published some interesting observations on the physiognomical ex- pression of certain forms of disease in children. According to his observations, there are three principal physiognomicaWm//.?, which, in children, are often very conspicuous—each indicating a peculiar morbid condition of the system. The first consists of a distinct pale or lead coloured streak with an appearance of depression, commencing at the greater angle of the eye, and terminating a little below the projection formed by the cheek bone. This he calls the oculo-zygomatic trait. This trait indicates disorder of the " cerebro-nervous system." It is strongly marked in all those maladies whose primary and principal seat is in the brain or on the nerves. It is likewise present whenever the nervous system, more especially the brain, participates actively in affections which are in the first place located in other structures or organs; but in cases of this kind, some other facial trait usually co-exists, which indicates the character of the complication. Thus, for instance, when intestinal irritation from worms or other causes, finally occasions hydrocepha- lus, epilepsy, &c, the oculo-zygomatic trait will be added to the previous physiognomical expression indicative of the intestinal disor- der. The second trait begins at the upper part of the alas nasi, and em- braces, in a semicircle more or less complete, the outer, line of the orbicularis oris. It is not uncommon to observe, towards the middle of the cheek and forming a tangent with this trait, another one which in certain faces constitutes the dimple of the cheek. These two traits, says M. Jadelot, are referable to similar affections. The first he calls nasal, the second genal. This trait, and its accessory, indicate disor- der, particularly chronic irritation or inflammation of the alimentary canal, and of the abdominal viscera. It is observed in diarrhoea, indi- gestion, verminous irritation, &c. The third trait begins at the angle of the lips, and is lost on the margin of the chin. This is called the labial trait. It seldom forms a deep line, being modified by the changes which the neighbouring parts undergo. The other traits are more or less deeply marked according as the diseases to which they belong are more or less severe or protracted in their course. This trait attends diseases of the heart and of the respiratory organs, and may almost always be observed in cynanchae, carditis, hydro-pericardium, organic affections of the heart, pneumonia, &c. M. Salle observes, that at the onset of all severe diseases, the inspection of the child's countenance may serve as a useful guide to the physician in discovering the organ principally affected. " The presence or absence of the oculo-zygomatic trait, in the initial stage of the disease, will inform him whether the cerebro-nervous system be primarily affected, or whether its supervention be merely the result of sympathy." He asserts that at a single glance he has often been GENERAL DIAGNOSIS. 87 enabled to pronounce with confidence the existence of abdominal dis- ease, by observing the presence of the nasal trait. It is said to be particularly conspicuous in dysentery, and chronic diarrhoea. I have, for several years past, attended very carefully to these observations of M. Jadelot, and am entirely persuaded that they are correct, and of essential service in the diagnosis of certain diseases of children. In addition to these physiognomical expressions, the singular change of countenance which, according to Dr. Wolff',* occurs in chil- dren labouring under chronic or sub-acute peritonitis, deserves to be mentioned. This writer asserts that in the hydropic stage of this affection, " the skin at the root of the nose, immediately between the eyes, "acquires a swollen or bloated appearance, by which the gene- ral expression of the countenance is strikingly altered. " The parents of my patients" he says, " frequently noticed a change in the expres- sion of the countenance, without being able to say in what it consisted; but as soon as I directed their attention to the tumefaction of the skin at the spot mentioned, they agreed with me, that the change in the appearance of the child's countenance arose from it, and were sur- prised that they had not discovered it themselves." This singular trait, he asserts, is one of the most constant and certain diagnostic signs of the disease, after serous effusion in the abdomen has commenced. Sprengle observes, that chronic disease of the spleen is, almost invariably, attended with a remarkable bluish tinge of the tunica albuginea. I have verified this observation in several instances.— During my term of attendance last winter at the Commercial Hos- pital of this place, a patient was brought into the house, labouring under some chronic malady. At the first glance of his countenance, I noticed the singular blue tinge of the albuginea. I pointed it out to the students in attendance, and stated the diagnostic inference which, according to the observations of Sprengle, this appearance justified—namely, that the patient was labouring under some chronic affection of the spleen. This man has since died, and on post-mortem examination, the spleen was found very much enlarged, and other- wise disordered in its structure. Pain, whether from spasm or inflammation, always causes a peculiar contraction of the muscles of the countenance. The physiog- nomical expression of pain is, indeed, so characteristic that the most inexperienced will readily interpret it correctly. An attentive and experienced observer may even perceive, in the peculiar contraction of the features, in what class of organs, or in what organ, the cause of the pain is seated. Thus when the diaphragm is inflamed, the pain, from the situation in which it is felt, might be supposed to be seated in the stomach, the liver, or the spleen; but the peculiar grin- ning expression of the countenance, {risus sardonicus,) which attends injuries, or inflammation of the diaphragm, indicates, at once, the true seat of the disease. Pain depending on inflammation of the mucous membrane of the *Hufeland's and Osan's Jour, der Rractischen, Heilkunde, May, 1829. 88 GENERAL DIAGNOSIS. alimentary canal, generally gives an expression of gloom, irascibility and discontent to the countenance; and this is more especially the case when the stomach and duodenum are affected. When the lungs are the seat of painful sensation, there is an expression of great anx- ietv depicted in the countenance, attended with an unusual expansion of'the nostrils, during each inspiration. Even, when there is no acute pain, in affections of the lungs, this peculiar anxious expression of the countenance and expansion of the alae nasi, generally occurs, in consequence of the congested condition of these organs impeding the respiratory functions. Dr. Marshall Hall observes, that the more acute the pain is, in inflammation of the thorax, the more contracted, in general, will be the features. When the pain is very severe, the alae nasi are acute, and elevated, and the nostrils are strongly con- tracted and expanded, by the alternate acts of respiration. In addition to this, there is sometimes a vivid flush on the cheeks, termi- nating abruptly, and bounded by a very pale streak towards the nose. "In great difficulty of breathing, from a congested state of the lungs, the countenance is not only marked by an expression of anxiety, but becomes, also, more or less suffused with a dark or livid hue, accom- panied with turgidity or fulness. Whenever, therefore, this livid appearance, and turgidity of the vessels of the face occur, in diseases of the lungs, we may be assured that there exists either great san- guineous congestion in these organs, or an effusion of fluid into them. This is still more certainly the case, if with these physiognomical signs, the surface of the body is rather below the natural tempera- ture. The countenance peculiar to tubercular phthisis is so striking, that even the most careless observers, in general, readily recognize it. The delicate paleness of the face ; the circumscribed flush on the cheeks in the afternoon; the pearly whiteness of the tunica albuginea; the quivering motion of the lips and chin in speaking, are well known as the invariable and ill-boding attendants of pulmonary con- sumption. In " inflammation of the abdominal viscera," says Dr. Hall, " at- tended with severe pain, the muscles of the face are in a state of continued contraction ; the features are unnaturally acute, the fore- head is wrinkled, and the brows knit. The nostrils are acute and drawn up ; the wrinkles, which pass from them obliquely downwards, are deeply marked, the upper lip is drawn upwards, and the under one frequently downwards, so as to expose the teeth. The state of the features is aggravated on any increase of the pain from change of position or external pressure. When the abdominal pain arises from spasm, the muscles of the face are exceedingly contracted and distorted during the paroxysms of pain; but in the intervals of the paroxysms, the countenance assumes a calm and placid aspect." In organic affections of the heart, the countenance generally ac- quires a very peculiar expression. In cases of this kind, the prolabia are more or Jess livid, the face puffy or cedematous, and of a peculiar dingy hue, or suffused with a livid flush. This circumstance is worthy of notice, in relation to the diagnosis between organic affec- GENERAL DIAGNOSIS. 89 tions of the heart, and hydrothorax. In the latter affection, the countenance almost always exhibits a pale, or pale livid aspect, in- stead of the vivid flush so common in cardiac diseases. (Hall.) In the soporose affections, also, the countenance is variously and characteristically affected, and affords important diagnostic indica- tions. In the apoplectic attack, the face is generally flushed, or livid, and the blood-vessels of the head and neck turgid. The muscles of the face are frequently paralytic on one side, so as to destroy the natural symmetry of the features, the mouth is drawn towards the unaffected side, whilst the eyebrows, nostril, angle of the mouth, and cheek of the paralyzed side sink down. The flush and fulness of the face do not, however, continue throughout the whole course of the disease ; towards the fatal termination of the attack, the counte- nance usually becomes pale, and somewhat contracted. In syncope, the countenance is pale, shrunk, and covered with a cold perspiration, presenting a death-like appearance; and in that state of insensibility which sometimes occurs in hysteria, the countenance is nearly natu- ral, both in colour and expression. In the two latter affections there is no unusual sanguineous congestion in the head. The blood is accumulated in the lungs and heart, and hence, when recovering from the state of insensibility, patients generally experience a sense of great weight and pressure in the chest, more especially in the region of the heart. Chlorosis is always attended with a very peculiar and characteris- tic appearance of the countenance. " The incipient stage is denoted by paleness of the complexion—an exsanguious state of the pro- labia, a slight appearance of tumidity of the face, or fulness of the eyelids." In some instances, a tinge of green, or of yellow is ob- servable in the pallor of the countenance, and the eyelids are of a dark lead-coloured hue. " In the confirmed stage of the disease, the face is still more pallid; the prolabia acquire a slight lilac hue, and the integuments, in general, a puffy and tumid appearance. In the more chronic form of this malady, the countenance exhibits an ap- pearance of sallowness, of squalid or dingy paleness, with a ring of darkness occupying the eyelids, extending a little towards the temples and cheeks ; and in some instances a similar dark streak surrounds the mouth." Dr. Hall observes, that this sallowness or icterode ap- pearance of the countenance, must not be confounded with the differ- ent shades of icterus, or bilious tinge. In icterus or jaundice, that is, when the discoloration depends on the deposition of bilious matter, the tunica albuginea of the eyes, is invariably more deeply tinged with yellow, than any other portion of the surface ; whereas, in the more icterode, or sallow appearance of the complexion, observed in chlorosis, and in some other chronic affections, the eyes do not exhibit any distinct tinge of yellow. When, therefore, the countenance of a patient presents a yellowish hue, without a similar tinge of the albu- ginea, we may conclude, that it does not depend on the presence of bilious matter in the circulation, or on biliary derangement. In chronic irritation of the bowels, from worms, or other irritating substances lodged in the alimentary canal, a remarkable pale tume- 90 GENERAL DIAGNOSIS. faction of the upper lip frequently occurs, in connection with the na- sal and genal traits, mentioned above. This swollen state ol tne ups is generally but transient in verminous affections. It usually comes on at night, during sleep, and seldom continues more than two or three days. A somewhat similar swollen state of the upper lip often occurs in children affected with scrofula ; more especially when the disease is principally seated in the mesenteric glands. In cases ot this kind, however, the tumefaction is much more permanent; there is also more lividity of the prolabia and the cheeks, and the peculiar trait mentioned by Jadelot, (the nasal and genal,) are not present In inflammation of the arachnoid membrane, the expression ol the countenance is generally strikingly characteristic. Besides a general expression of surprise, confusion, and discontent which it is impossi- ble to describe, but which cannot easily be mistaken when once seen and contemplated, the most prominent morbid expressions of the countenance are those furnished by the eye. According to the ob- servations of Martinet and Duchatelet, the pupils are either much dilated or contracted; the conjunctiva presents a greater or less de- gree of redness ; and when the inflammation has made considerable progress, and is about terminating in effusion, or structural lesion of the brain, there is squinting, and constant rolling of the eyes, or they are turned upwards so as to conceal the cornea. In nearly all instan- ces, the upper eyelids become paralyzed, so that the patient, in en- deavouring to look at any object, is unable to raise the lids by their proper muscles, and is therefore obliged to draw them upwards, toge- ther with the integuments of the forehead, by the contraction of the occipito-frontalis muscle.* Martinet observes, that these latter symp- toms, namely, the turning up of the eyes and paralysis of the upper eyelids, are the most constant symptoms manifested by the counte- nance in this disease. Whytt and Camper also declare that they are among the most certain diagnostic signs of this dangerous malady. Sprengle (Handbuch der Semiotik) says, that the appearance of the tunica albuginea affords an excellent diagnostic sign between scarla- tina and measles. In the former, he asserts, the albuginea exhibits a uniform red tinge, with little or no suffusion of tears; in the latter malady, the redness is not general or uniform, the injected capillaries of the conjunctiva leaving intermediate spaces of a natural or white colour. (Ziegler's Beobachtungen, p. 24.) The countenance in common synochus, or general inflammatory fever, usually exhibits a very different aspect from that which occurs in fevers depending on acute local inflammation seated in the thorax or abdomen. In the former, the face is more or less tumid and flushed, the conjunctiva of the eyes is injected or red, and " the ndstrils are rapidly and conspicuously dilated and contracted by the hurried re- spiration." In acute symptomatic fever, on the contrary, the counte- nance is generally somewhat pale and contracted, and there is no hurried movement of the nostrils, nor redness of the eyes, if the in- * Recherehes sur l'lnfiammation de l'Arachnoid, Cerebrale et Spinale. Par Duchatelet et L. Martinet, Paris, 1821. GENERAL DIAGNOSIS. 91 flammation be not seated in the head. In the acute bronchi'tis of infants the face is invariably remarkably pale: whereas, in infantile remittent and common synochus fever, from cold, it is almost con- stantly suffused with a flush. It must be observed, however, that in the advanced stage of pneumonic inflammations, whether in infants or adults, when the minute bronchial ramifications have become loaded with mucus, or serous effusion has taken place into the pulmonary tissue, the countenance acquires a more or less distinct livid hue—a phenomenon always indicative of great danger. On the other hand, the countenance, which is flushed in the early stage of synochal or remitting fever, becomes pale and somewhat shrunk, towards the termination of the disease. I pass on in the next place, to notice those diagnostic circumstances which relate to the altitude and motions of the patient. The mor- bid variations of attitude are best understood, by contrasting them with the healthy postures of the body during sleep. " It may be presumed, that, both in health and in disease, that posture is assumed which affords the most repose to the system in general, and most relief in the performance of its various functions. In healthy and undis- turbed sleep the usual posture is that of one side ; the head and shoul- ders are generally somewhat raised, and, together with the thorax, bent gently forwards; the thighs and legs are in a state of easy flexion. The position is apt to be changed from time to time, the person lying on one or the other side alternately. The posture of the body during sleep, here described, is such as affords the most ease and repose to the different viscera, and most facility and disincumbrance in the per- formance of their functions, and such as allows of the greatest mus- cular relaxation compatible with these more essential points." The supine position (decubitus dorsalis) when attended with twitching of the tendons, or tremor of the extremities, always indi- cates great muscular debility. When in the progress of a continued fever, we find the patient to assume this posture with the inferior ex- tremities extended, we may presume from this symptom alone, that the disease is assuming a sinking or typhus character. This is still more decidedly the case, when in connection with this position the patient gradually slides down towards the foot of the bed. It requires much less muscular exertion to maintain the supine posture than any other that can be assumed. In a very debilitated condition of the system, there is not enough of muscular power to preserve the body in the lateral posture. If the patient be placed on one side, he soon turns on his back, and is utterly unable by his own exertions to re- sume the lateral position. Celsus observes, that when a person affected with fever lies on one side, with the legs slightly retracted, he may be regarded as not in a very dangerous condition. In relation to the degree of muscular energy manifested by patients, there exists a marked difference between idiopathic and symptomatic fevers. In common acute fevers of an idiopathic character, the pa- tient soon feels very weak, and cannot support himself in the erect posture, without great and exhausting efforts, and a feeling of faint- ness. This is rarely the case in symptomatic fever. In fevers of 92 GENERAL DIAGNOSIS. this kind, the sense of prostration is seldom great, nor do we observe the muscular tremor, vertigo and faintness on assuming the erect position. In the diseases of the chest, the position assumed by the patient is often highly characteristic. In hydrothorax, the patient usually lies with the head and shoulders considerably elevated, by additional pil- lows. When out of bed, he is often observed to sit up, with the arms placed along the side, and the hands fixed and pressing forcibly on the chair or sofa on which he sits; in other cases he leans a little back- wards, still supported by the arms and hands, which are placed be- hind his back. " This kind of posture is often constant, or immedi- ately resumed, if any accident occasions it to be changed ; it gives rise to an elevation of the shoulders, from which the body is supported, or as it were suspended." The attitude of course varies with the de- gree and progress of the hydropic effusion in the chest. In order that the patient may continue to enjoy some rest while lying down, the head and shoulders must be more and more raised, until, at last, he is, sometimes, incapable of remaining in bed, and is obliged to sit up "with the legs hanging down." When hydrothorax is associated with organic disease of the heart, or of the lungs, the necessity of remaining in the erect posture, is, in general, particularly urgent. These circumstances admit of a ready explanation. The effused fluid in the chest, produces distress and difficulty of breathing in pro- portion as it presses upon and impedes the free action of the lungs. In a recumbent position, with the head and shoulders low, it is obvious that the fluid must envelop and encumber a much larger portion of the lungs than when the patient is sitting up, or lying with the shoul- ders elevated; for in this posture the fluid sinks down to the bottom of the thorax and leaves a considerable part of the lungs free from its embarrassing pressure. Hydropic accumulation in the chest may be distinguished from mere organic disease of the heart or of the lungs, attended with symptoms resembling those of hydrothorax, by making firm pressure on the abdomen and attending to the effects. If there is thoracic effusion, the patient will experience general agitation, cough, and a sense of suffocation when pressure is thus made on the abdomen. This arises from the abdominal viscera being pressed up against the diaphragm, by which the fluid in the chest is raised, so as to embarrass the lungs and cause the phenomena just mentioned. In organic affections of the heart, without thoracic effusion, no effects result from abdominal pressure. In affections of this kind, as well as in hydrothorax, the patient is unable to remain easy in a recum- bent posture with the head low, more especially in very severe cases. But in addition to this circumstance, the effects which arise from corporeal exertions in organic affections of the heart, are much more violent and distressing than in hydrothorax. Almost every muscular effort or unusual exercise produces, to an extreme degree, dyspnoea, anxiety, and agitation. Ascending stairs, or a hill, seldom fails to bring on a paroxysm of the most alarming palpitation, and suffoca- tive breathing. Although similar effects result from the operation of these causes in hydrothorax, yet, they are much less violent and GENERAL DIAGNOSIS. 93 alarming than in cardiac diseases. When in hydrothorax, the drop- sical effusion exists only on one side of the chest, the patient invaria- bly lies on the affected side. Inflammation in the abdomen, with acute pain, is in general attended with a characteristic position of the body, and which dis- tinguishes affections of this kind, very pointedly, from spasmodic pains of the stomach and bowels. In acute abdominal inflammation the patient assumes a certain position and carefully avoids active muscular exertion and change of posture. In spasmodic pains in the abdomen, or colic, on the contrary, the patient usually "writhes to and fro," and constantly changes his posture. In abdominal inflammation the patient lies on the back, with the knees drawn up, and the head and shoulders raised by additional pillows, so as to relax the abdominal muscles and obviate as much as possible, pres- sure on the inflamed viscus. Great care, moreover, is taken to pre- vent any pressure from the hands or bedclothes on the abdomen, and all the necessary motions of the body are performed with pecu- liar caution and slowness. In spasmodic or colic pains, so far from avoiding pressure on the abdomen, the patient often lies on the belly, or presses forcibly on the bowels with his hands. After the paroxysm of pain in colic is over, the patient resumes an easy position; but in the absence of an aggravation of inflammatory pain, the same cau- tious posture and manner are still retained as before. (Hall.) When the inflammation is seated in one of the kidneys, the patient when in bed, inclines his body a little forwards and towards the side affected. By this position the muscles of the loins on the affected side will be somewhat relaxed and the pressure on the inflamed kid- ney diminished. When, in the advanced stages of typhous or typhoid fevers, attended with delirium, the patient is observed to keep his inferior extremities constantly drawn up, while recumbent on the back, retention of the urine may be suspected. I have known patients affected with typhoid fever, and in such a condition as not to be able to give an account of their sensations, in whom protracted retention of the urine was detected solely by noticing this retraction of the legs, or constant raised position of the knees. In most instances of inflammation of the liver, the patient cannot lie on the left side without great aggravation of his sufferings. This symptom is, indeed, not always present in hepatitis, and when taken by itself, cannot be regarded as of any particular diagnostic import- ance. When it occurs, however, in connection with other symptoms indicative of hepatic inflammation, it may be considered as no incon- siderable evidence of the existence of this affection. If in a case of hepatitis, the patient is observed to lie easiest on the left side, we may infer that the inflammation is principally seated on the concave sur- face of the liver. Next in order are the diagnostic signs manifested by the tongue, nausea and the vomiting, greatly abate— the pulse returning to its natural standard, and the skin acquiring a moist and temperate condition. So' complete, indeed, is the remission in some cases, that the patient is induced to flatter himself that all danger is now passed. More commonly, however, the patient re- mains in a state of tranquil indifference, amounting to a sort of stupor, without any apparent concern as to present or future situation. This is an ominous calm; for, after a few hours, the pain and burning sensation in the stomach return with increased violence ; the vomit- ing becomes frequent and distressing—the fluid brought up containing minute flakes or flocculi, resembling the crust washed from a port- wine bottle, but little or no bilious matter. The desire for cool drinks is extremely urgent, but every thing which is swallowed is imme- diately rejected by the stomach, with great force. The eyes and skin about the neck and breast now acquire a yellow hue. This second paroxysm continues, commonly, from twelve to thirty-six hours, and is succeeded by a new train of symptoms, which mark the last or third stage of the complaint. The pulse now sinks in frequency, force, and volume; the tongue is dark-brown or black; the vomiting YELLOW FEVER. 147 becomes almost incessant, and exceedingly forcible, the matter thrown up consisting of a black ropy fluid resembling coffee grounds sus- pended in a glairy liquid. The extremities become clammy and cold; and the acrid or burning sensation in the stomach, acquires a most distressing degree of violence. Diarrhoea usually occurs at this period—the discharges being green or black ; " and the patient often complains of being unable to pass his stools, from a want of power in the abdominal muscles." By this time the whole surface of the body is a dirty yellow colour; and hiccough, hemorrhages, violent deli- rium, coma, insensibility, or convulsions, sooner or later terminate the patient's sufferings in death. Such is the ordinary course of this fatal malady. In many instances. however, the attack is much more overwhelming ; the patient being seized at once with loss of muscular power, and general oppression of the nervous system—falling down as if stunned with a blow. In other instances, violent and furious delirium, or mania, ushers in the disease, terminating in a few hours in insensibility and convulsions. Sometimes the disease commences and proceeds to a fatal termination in so insidious a manner, that the patient himself and those about him are scarcely aware that he is much indisposed. In such cases there is, however, always a remarkable change in the expression of the patient's countenance, as well as his usual temper and habits. In almost all instances of this disease, the countenance is expressive of intense anxiety and despair during its early period, and of gloomy or sullen abandonment in the last stage. The period at which the skin begins to assume a yellow colour, is very variable. It sometimes occurs within the first forty-eight hours, and sometimes not until the fourth or fifth day. Various opinions have been expressed with regard to the immediate cause of this yellow hue of the surface. Some ascribe it to the serum rendered yellow by dissolved red globules of the blood, and effused under the cuticle. Dr. Fordyce attributes it to the superabundant secretion of sebaceous matter by the glands of the skin; and Dr. Saunders supposed it to depend on a peculiar state of the lymph in the sub- cutaneous cellular tissue. Many, however, maintain, and with cor- rectness, I think, that the yellow hue, in question, is of an icteric character, depending entirely on the deposition of bilious matter under the cuticle. The black matter thrown from the stomach in the latter period of this disease, does not consist of bile, as was once generally supposed, but of minute flakes of coagulated blood suspended in the gastric mucus, produced by sanguineous exhalation from the abraded sur- face of the mucous membrane of the stomach. The black matter discharged in some of the higher grades of bilious and typhus fevers differs essentially from the " black vomit" of yellow fever. The former will dissolve in water, and communicate a deep bilious tinge to it; whereas the black matter which forms the black vomit of the present disease, consists of small insoluble flakes which are held suspended in a viscid fluid, and will not communicate a yellow or greenish tinge to water when agitated with it. " In taste also they 148 YELLOW FEVER, differ. The black matter which occurs in common bilious fever, is always intensely bitter; but that which is thrown up in yellow fever, is either insipid or acid."* (Bancroft.) Post-mortem appearances.—The stomach and liver are the organs upon which the disease exerts its principal force. The former, espe- cially, always shows the strongest marks of previous inflammation and its consequences. Its coats are often thickened, and the mucous membrane is always stronely injected, abraded, and in many parts gangrenous, or totally disorganized. The duodenum and small in- testines also almost invariably exhibit marks of inflammation. In many of the more aggravated cases, the liver undergoes much struc- tural derangement. Dr. Chisholm has found the liver "in a dissolved or putrid state or sphacelated, and of the consistence, feel, and colour of rotten cork, or full of abscesses." Dr. Physick rarely found the liver much diseased, but the stomach was always inflamed and gan- grenous in parts.t Causes.—In relation to the origin and mode of dissemination of yellow fever, physicians have been at great variance ; and the subject is still much disputed, although the weight of good testimony is greatly on the side of its miasmatic or domestic origin. After an attentive examination of the principal observations which have been published on this subject, it appears, indeed, difficult to adopt any other opinion than that which alleges its origin from miasmatic efflu- via, " exhaled from masses of public filth containing putrescent mat- ter, generated under a high range of temperature." That this is the case, seems to be sufficiently demonstrated by the following circum- stances:—1. Yellow fever always appears in the lowest and most filthy parts of towns; and those localities in which it is most preva- lent, are in the immediate vicinity of marshes or soils favourable to the production of miasmata. 2. Yellow fever never occurs in cold seasons—a high range of atmospheric temperature being essential to the generation of its cause. 3. Heavy rains, storms, and the super- vention of cold weather, never fail to put an immediate check to the disease.^ 4. Yellow fever always appears simultaneously, and is in- termixed with bilious remittents. Dr. Ramsay states, that in the yel- low fever of Charleston, in 1804, "neglected intermittent frequently terminated in yellow fever." Dr. .Rush also states, in relation to the yellow fever in this city in 1802, that "intermittents, the mild remit- * Mr. Lyon, staff surgeon in the Island of Dominica, says that the black matter ejected from the stomach in yellow fever, is invariably very strongly acid. He ascribed the black colour of the blood to the action of muriatic acid on it; for it is this acid, which, according to the investigations of Prout and others, is secreted by the stomach in a state of disease, " Having made the experiment of adding muriatic acid to blood, the colour of the bloQd was instantly changed to a deep black, and when diluted with water, presented a liquid, which I should have declared from mere inspection, to be black vomit."'—Lond. Med. and Phys. Journ., 1829. f New York Medical Repository. X Rush's Medical Inquiries YELLOW FEVER. 149 tent, the inflammatory, bilious, and the malignant yellow fever, have in many instances all run into each other ;"* and he observes that Dr. Saunders, nearly a century ago, noticed this conversion of marsh and yellow fever into each other. Yellow fever is, moreover, always most severe in the immediate vicinity of those localities which favour the generation of marsh miasmata. Dr. Caldwell, speaking of the yellow fever of this city in 1803, says, " as the fever receded from the low ground and malignant atmosphere of Water street, it became more and more mild and manageable till its evanescent shades in Second street were, in many instances, much lighter than the common remittent of the country." During the prevalence of the yellow fever in Baltimore, "the bilious or remitting fever in its ordinary form, prevailed in that town and continued until it was gradually lost in the severer form of yellow fever as the season advanced." (Davidge.) 5. The miasmatic origin of the disease may be inferred also from the fact, that the recurrence of it has often been, in a great measure, pre- vented by removing the sources of pestiferous exhalations, in situa- tions where it formerly prevailed, almost annually, to an alarming extent. Our own city may be cited as a prominent example of the efficacy of cleanliness in preventing the occurrence of this disease. (Bancroft.) If these views be correct, in relation to the origin of the disease, we are forced to reject the opinion so stoutly maintained by some, of its being in any respect contagious. Indeed, if yellow fever did possess the power of generating its own virus, and commu- nicating itself by contagion, the fact, as Dr. Bancroft observes, must have been proved ten thousand times by the most irrefragable testi- mony, and yet there is, perhaps, no incontestable case on record where the disease was thus communicated. The city hospitals esta- blished in the neighbourhood of this city and at New York, furnish us with a striking refutation of the supposed contagious nature of this disease ; for, in no instance, was the disease communicated to those who were employed about the sick. The same observations were made at the encampment near Baltimore, during the prevalence of this disease in that city in 1819. The recent very ample investigation of this subject by Dr. Chervin, has resulted in a mass of testimony,, which can scarcely leave any pretext for doubting the non-conta- gious nature of this disease. But, although yellow fever be not con- tagious, it may, no doubt, be introduced into seaport in ships Unques- tionably, a pestiferous miasm may, under favourable circumstances, be generated in the holds of ships while navigating in hot climates which, when suffered to escape at the wharves, may give rise to the disease in question. When the miasmata are thus introduced, how- ever, the disease engendered by it will not prevail epidemically, but only among those who approach the infected vessel, or the cargoes, and will disappear entirely when these are removed to a distance. (Bancroft.) The sporadic cases which occurred at the Wall, about 1804, at Perth-Amboy, in 1811, at Middletown, in Connecticut, in 1819, and at New York, in 1824, were distinctly traced to vessels that * Medical Repository for 1802. 150 YELLOW FEVER. had recently arrived from warm climates. The circumstances of the ship Ten Brothers, at Boston, in 1819, afford a striking example of the production of deleterious miasm in the holds of ships, capable of producing yellow fever.* This vessel having arrived at Boston on the first of August, a number of persons went on board while the cargo was being discharged ; and out of these, twelve individuals, living in various parts of the city, were seized with malignant fever, nearly all of whom died. The disease was not, however, commu- nicated to a single person of those who visited the sick. Observation would seem to show, that those who had once suffered an attack of this disease, are afterwards, in a great degree, insuscepti- ble of another attack. In hot climates, where the disease is endemic, persons recently arrived from more temperate latitudes are almost exclusively obnoxious to this disease. The acclimated are, in a great degree, exempt from its attacks, and when it does occur in such in- dividuals, it almost always is of a comparatively mild and tractable character. The influence of the remote cause of this form of fever is greatly promoted by intemperance, excessive exercise in the sun, exposure to a damp and cold night air, and, in short, by whatever is capable of debilitating either the whole system, or deranging import- ant organic functions. Treatment.—If yellow fever has been a fertile subject of dispute in relation to its pathology and cause, it has afforded no less scope for contention with regard to its remedial management. Whilst some strenuously recommend a prompt and energetic treatment, others, condemning the lancet, mercury, and active purgation, advise nothing but the mildest and most soothing remedies. From a careful estimate of the best authorities on this head, however, it would appear that the chances of success are on the side of an energetic plan of treatment. This disease is highly phlogistic, and gastro-enteric inflammation is a very common occurrence—more especially in young, robust, and un- acclimated subjects. In cases where the arterial reaction is vehement in the onset of the disease, general blood-letting is often promptly and conspicuously beneficial. To obtain the full advantages which this evacuation is capable of affording, it must be early and very efficiently practised. Those who have employed blood-letting with the greatest success, are unanimous in restricting its use to the first stage of the disease. Dr. Robertson, in his account of the yellow fever of New Orleans, states, that during the first twelve hours, he frequently drew from fifty to sixty ounces of blood;t and Dr. Belcher bled to the extent of from fifty to eighty ounces in the first stage, with much advantage.J In a disease so impetuous in its attack, and so apt to develop local inflammations, much, and often every thing, depends on an early and powerful antiphlogistic impression on the system. Where the reaction of the heart and arteries is vigorous, the blood should be suffered to flow until fainting approaches, "for it * Medical Recorder. f Johnson on Tropical Climates, vol. ii. X Edinburgh Med. and Surg. Journal, 1825. YELLOW FEVER. 151 is not only by unloading the vessels, but by the shock also which it gives to the system, that blood-letting proves so serviceable in inflam- matory fevers." Dr. Anthony Musgrave states, that as soon as the febrile reaction was developed, after the invasion of the disease, he derived the greatest benefit from the immediate and rapid abstraction of blood, to an extent limited less'by the quantity than by its decided effect upon the action of the heart and arteries.* Dr. Rush, as is well known to the profession of this country, was a zealous advocate for blood-letting in the disease. " I paid no regard," he says, " to the dissolved state of the blood, when it appeared on the first or second day of the disorder, but repeated the bleedings afterwards in every case when the pulse continued to indicate it." " In a disease like this," says Dr. Robertson, " where the danger is frequently imminent in twelve hours, it is often surprising to see how much its apparent character may be altered by active depletion." A host of other able practitioners might be cited in behalf of the usefulness of this practice. In those instances of the disease, however, where the nervous system appears to be in a manner overwhelmed by the remote cause of the fever, when the patient exhibits an air of confusion or intoxication, with great agitation, " and a dash of wildness gleaming at intervals over his agonized features;" when he complains of little or no head- ache, but is impatient and irritable, yet oppressed; and after the first days sinks down with a careless expression of resignation—in such cases blood-letting is wholly inadmissible. Here we must rely chiefly on the prompt and liberal administration of calomel with a view to its salivant operation. The efficient abstraction of blood in the commencement of the disease serves not only to break down the violence of the phlogistic excite- ment, but often contributes materially towards allaying the excessive irritability of the stomach, frequently so distressing in this malady. Purgatives, also, are highly useful remedies in this disease, though, like blood-letting, their good effects are almost entirely confined to the early periods of the disease. Calomel and jalap, in doses of ten grains of each, was a favourite purgative with Dr. Rush. As calomel is, however, very generally admitted to be one of our most useful remedies in this disease, both on account of its purgative effects and its specific constitutional influence, it will be better to exhibit it by itself in doses of from ten to fifteen grains every three or four hours, and to promote its purgative operations by laxative enemata, after the second or third dose has been taken. In this way copious alvine discharges will generally be effected, and the system early brought under the mercurial influence. Should the bowels, however, not be sufficiently evacuated by these measures, a dose of Epsom or Glauber salts ought to be administered. When the bowels have been thus once freely evacuated, they must be kept in a loose state by means of the milder laxatives; such as Seidlitz powders; small portions of the saline purgatives, or the occasional use of enemata. It should be observed, however, that mercury, with a view to its constitutional * Treatise on the Yellow Fever of Antigua. 152 YELLOW FEVER. operation, can seldom be serviceable, so long as the arterial action remains unsubdued in the commencement of the disease. Indeed, almost all attempts to produce ptvalism under such circumstances are fruitless. Decisive blood-letting in cases of this kind must be regarded as an essential preliminary to the use of mercurials. In cases of less vehement grade of febrile reaction, where the disease assumes more of a congestive character, the early induction of sali- vation is particularly desirable—and our principal object should be to produce this effect as speedily as possible. Dr. Musgrave observes, "that in the more concentrated form of yellow fever, experience leads me to believe that mercury, administered with a view to its salivant effects, may be judiciously dispensed with. But there is a form of this disease which, from its insidious approach, is peculiarly calculated to lull the patient into mistaken security," and thus to baf- fle, in its subsequent progress, the best directed efforts; and this form is undoubtedly treated with great success by the rapid induction of ptvalism.* In cases where the febrile reaction is strongly developed, the skin is always extremely hot and dry during the first period of the dis- ease, and nothing is more refreshing than sponging or ablutions with cold water under such circumstances. Most writers prefer pouring it forcibly on the patient's body. Dr. Johnson observes, that " the greater the force with which the water is applied, the more benefit will be derived from it."t When the head is much affected during the first stage, considerable benefit may be obtained from cold appli- cations to the shaven scalp. Bladders partly filled with water con- taining a lump of ice, is the most convenient and effectual mode of applying cold to the head. For the same purpose blisters are recom- mended by some, but their usefulness in this respect is very question- able, and certainly much inferior to the application of cold, so long as the arterial reaction is vehement. Draughts of cold water are gene- rally very grateful to the patient, and have the effect often of mo- derating the heat, predisposing to perspiration, and of relieving the gastric distress. (Johnson.) Emetics are very generally, and with justice, condemned in the treatment, of this disease. The gastric irritability and tendency to inflammation is so great in this affection, that mischief would almost inevitably result from the operations of this class of remedies. Nevertheless, we are told by Dr. M'Arthur, that where the disease commences with diarrhoea or dysenteric symptoms, emetics may be frequently given with considerable advan- tage. Besides the means already mentioned for allaying the extreme irritability of the stomach, and restraining the vomiting so distressing in the disease, we may also derive much advantage from the appli- cation of leeches or blisters to the epigastrium, more especially after the impetus of the circulation has been in some degree moderated by an efficient bleeding. When the disease has passed on to the second period, we must depend on the use of mild aperients, diaphoretic and * Edinburgh Med. and Surg. Journal, 1827. t Influence of Tropical Climates, vol. ii, p. 182. CONTINUED FEVER. 153 cooling beverages, enemata, cold affusions when the skin is hot and dry, and calomel, in reduced doses. A great deal, however, of the success of our remedial efforts depends on the proper management of the disease in the first period. As a diaphoretic, we may use the spiritus mindereri, or the saline effervescing draught. When, after the second exacerbation, the pulse and temperature sink, recourse should be had to the active tonics—and of these, the cinchona or quinine is the most efficient. The latter, especially, seems to have done,much good in this disease." These articles should be adminis- tered in as large and frequent doses as the stomach will bear. Dr. Musgrave resorted to the cinchona in the less vehement cases, with much good effect, as early as the first remission, having previously evacuated the bowels thoroughly. From five to ten grains of qui- nine may be given every hour or two during the remissions, and it may be given in conjunction with calomel, during the first periods of the disease. In the latter stage of the disease, the bark, quinine, wine, and am- monia, constitute almost the only remedies that can be employed with any prospect of advantage. Stimulants, however, are not so well calculated to do good in the sinking stage of this form of fever, as in that of typhus. The spirits of turpentine has also been recommended in the treatment of yellow fever, but it does not appear that its powers are sufficiently valuable in this respect to entitle it to much attention. It is proper to state that many of the West India practitioners adopt a plan of treatment far less energetic than the one just detailed. They employ little else than mild aperients, with copious draughts of acidu- lated drinks, enemata, and external cold applications. CHAPTER VIII. CONTINUED FEVER. Although the varieties of fever which are arranged under the present general head are termed continued, in contradistinction to the forms of lever considered in the two preceding chapters, yet, with the exception of the ephemera, a fever strictly continuous or unremitting in its course, is in reality a phenomenon of the rarest occurrence. Whether the operations of the animal economy be carried on in a state of health or of disease, regular periodical fluctuations appear constantly to obtain in the excitement or actions of the system. In every form and variety of fever, there seems to exist a natural tend- ency in the general morbid excitement or symptoms, to remit or abate in their violence at some period during the day ; and this remission, * Journal des Auslandishen Literature, &c. Von Drs. Julius and Gerson. 154 CONTINUED FEVER. in perhaps ninety-nine cases out of a hundred, occurs during the morning. In the fevers denominated continued, however, these tem- porary abatements in the violence of the symptoms are generally slight, and frequently very transient; they usually occur very early in the morning, and seem to be the result of the abstraction of the stimulus of light, sound, &c, during the night, in conjunction with the natural tendency of the actions of the system to abate at this period. Continued fever occurs under a variety of prominent modifications, and under every grade of febrile excitement, from the feeble, and sinking reaction of typhus, to the vehement and tumultuous actions of synochal fever. Agreeably to this circumstance, it has been cus- tomary to divide continued fevers into sthenic and asthenic, or inflammatory and typhus. That there exists a very material differ- ence between the low fevers denominated typhus, and those usually termed inflammatory, is quite obvious. The term inflammatory, nevertheless, does not seem to be strictly appropriate as a distinctive appellative in this place ; for that irritated excitement which consti- tutes fever is always necessarily inflammatory in its general charac- ter, whether the reaction be feeble and sinking, or vigorous and ardent. Mere grade of energy or activity is to be regarded as an accidental and variable quality Of inflammatory excitement. Fever consists essentially in an irritated action of the sanguiferous system, and this irritated condition may be connected either with increased or de- creased energy of the vital powers. In pure synocha, the heart and arteries are in a state of morbid action, with increased powers of acting; whilst in typhus fevers the general irritated excitement is connected with fundamental debility of the vital powers. In either case, however, the irritated vascular action is essentially phlogistic, and equally prone to give rise to local inflammations. The diversi- ties which occur in the general character of continued fevers, depend mainly on the differences which occur in relation to the degree of vital energy enjoyed by the system, and this diversity in the general energies of the system itself, would seem to depend on the greater or less degree in which the nervous system becomes implicated in the disease. The brain is the fountain whence the animal economy draws its powers of action; and whenever this source of the vital forces becomes injured or impeded in its operations, debility, corre- sponding to the degree and character of the cerebral affection, will be manifested in the actions of the system. In the high and vigorous synochal fevers, there are rarely any considerable manifestations of cerebral disturbance; whereas, in all those fevers which are attended with prostration and feebleness, the brain and nerves are generally prominently disordered throughout the whole course. There exists no small degree of difficulty in arranging continued fevers under such heads as will exhibit a distinct and comprehensive view of all the prominent modifications or forms in which they are wont to occur. In relation to 'the grade of febrile excitement, fevers may be divided into three principal varieties : namely, synocha, syno- chus, and typhus. 1. Synocha.—This head embraces all those fevers which are con- CONTINUED FEVER. 155 spicuously inflammatory, both in relation to their general and local phenomena. They are usually divided into idiopathic and symp- tomatic; the former, constituting what is generally termed simple inflammatory fever', and the latter, embracing those fevers which result from acute local inflammation. Hardness, quickness and ten- sion of the pulse, are essential characteristics of synochal fever; but in relation to the size and activity of the pulsey there exists great diversity in the different varieties of this grade of fever. In simple inflammatory fever the pulse is full, vigorous and hard ; whilst in some of the phlegmasia, in acute gastritis, enteritis and peritonitis, its volume is usually small, although its firmness, tension and quickness are conspicuous, and the necessity of prompt and vigorous depletory measures extremely urgent. The blood in synocha is thicker, and contains a smaller proportion of serum than in health, and is disposed to separate speedily and very completely into its constituent parts. The crassamentum becomes dense, concave, or cupped on its superior surface, and coated with a thick layer of yellowish fibrin. The albu- menoid, or coagulable portion of the serum, does not become con- densed when subjected to the action of heat, alcohol, &c, but is con- verted into a white pap-like matter. Boiling water poured into the serum of blood taken from a patient labouring under synocha, con- verts it into a whey-like fluid, resembling a solution of soap in water, without any coagulated flakes.* In synocha, the general energies of the system manifest no prone- ness to prostration, so long as the fever retains its simple character. The powers of vital resistance continue to the end, with no material impairment. When general fever of the synochal grade passes into a low or typhoid state, it is either in consequence of inordinate san- guineous depletion, or of the supervention of cerebral inflammation, or the occurrence of inflammation and gangrene in other organs. Simple continued fever of the synochal grade, is rarely attended with conspicuous symptoms of sensorial disturbance, or cerebral irri- tation ; nor is it common to meet with signs of gastro-intestinal irri- tation in cases of this kind. Fevers, however, rarely preserve the simple synochal character throughout their whole course. In most instances, local inflammation supervenes in some part or other. When the inflammation falls upon a fibrous structure, or upon one of the solid viscera, the energy of the febrile reaction will be increased, or at least sustained; but when it happens to appear in the mucous membrane of the alimentary canal, the brain generally becomes more or less oppressed, and the general powers of the system tend to a state of prostration. The secretions in synocha are almost universally diminished in quantity. Cold or atmospheric vicissitudes, and a high degree of solar heat, are almost the only general causes of*this grade of fever. Synochus.—This grade of fever is intermediate between the purely * Reil. iiber die Erkentniss, kc, der Fieber. Band, i, s. 494. See also Par- mentier and Deyeux's Memoir in Reil's Archives fur die Physiologe and B. 1, No. 3, s. 5. 150 CONTINUED FEVER". synochial and the typhus varieties of fever, and constitutes by far the most common modification of febrile reaction. It is the grade of fever which occurs in intermittents, remittents, bilious fever, and the common continued fevers which arise from cold and from gastric irritation. The pulse of synochus fever is active, more or less full, frequent, compressible, and free from unusual tension or hardness. The blood itself rarely differs perceptibly from its natural character, being devoid of the above-named inflammatory characteristics. The system is much less able to resist the influence of debilitating causes than under the preceding grade of fever. It will bear a degree of depletion while labouring under synocha, which, in a fever of the synochus grade, would produce the utmost degree of prostra- tion. Synochus is employed here as indicating merely a certain grade of febrile excitement, and not as constituting in itself a distinct form of fever. The reaction of the heart and arteries is only one of the series of morbid phenomena which constitutes fever, and the same grade of vascular reaction occurs in maladies essentially distinct from each other. So far, indeed, as the mere action of the heart and arteries is concerned, fevers differ from each other only in degree; or, to adopt the language of Parry, in the greater or less momentum of the blood. It is in the capillary system of vessels, that the funda- mental morbid condition resides, which establishes the essential dif- ference of febrile diseases. The morbid excitement of the capillaries in a case of small-pox must be very different, one should think, from that which occurs in this system of vessels in remitting fever, and both may nevertheless be attended with the synochus grade of febrile reaction. Typhus.—This grade of fever is lower than the preceding one, the vital powers being more prone to sink, and, in general, much less able to resist the influence of debilitating remedial measures. It is characterized by a weak, small, quick, and generally frequent pulse. In some instances, however, of a typhous state of fever, the pulse is nearly natural in frequency and fullness; but softness and feebleness are seldom absent, except in the commencement of the disease. An early disturbance of the sensorial powers, and a train of various nervous symptoms, almost universally attend fevers of the typhous kind. There are three apparently very distinct varieties of typhus fever. One of these varieties is characterized by what may be called a highly nervous state of the system—the patient manifesting along with a weak condition of the vital powers, a peculiar degree of nervous excitability and excitation, and an active state of the sensorial func- tions. This constitutes what was formerly usually described under the name of nervous fever, the typhus nervosus, pyrexia nervosa, neuropyra, typhus cum erethismo, and the febris nervosa simplex of authors. Another variety of typhus fever in connection with the deficient or sinking energies of the system, is characterized in its progress by phenomena which have been generally regarded as indicative of a SYNOCHA, &C 157 tendency to putridity; the pulse, at first moderately full and active, soon becomes soft, feeble, sometimes frequent, and at others slower than natural, the skin is pale dingy, or sallow, its heat elevated, and of the kind called calor mordax, or in some instances nearly natural, and sometimes even below the natural standard. The breath, secre- tions, and exhalations are offensive to the smell; petechiae, extra- vasations, colliquative hemorrhages from the gums, the fauces, the eyes, the bowels, &c, ensue towards the conclusion of fatal cases. This variety of typhus fever has been described under various de- nominations; such as f colliquativa, f. putrida sanguinea, f.pu- trida simplex, f. sepedogenetica, f. adynamica, typhus putridus, synochusputridus,pyrexia myoica, pyrexia denophlebica,f hsema- toseptica, septopyra, putrid fever, putrid nervous fever, typhus gravior, 4*c. There is a third variety of low fever, which, along with its radical tendency to prostration, is strongly characterized by a very conspicu- ous torpor of the sensorial, intellectual and general nervous func- tions. Its first stage is often attended by the synochus grade of vascular reaction, whilst the second stage is marked by torpor, great prostration, and feeble arterial action. Its different stages are more definite in their duration, and its essential phenomena succeed each other in a more regular order than those of other continued fevers. This constitutes the genuine typhus—the typhus coniagiosus of authors—a form of fever which by many is believed, and I think with correctness, to be radically diverse from every other form and variety of febrile disease. Having made these general remarks on the principal grades and modifications of continued fevers, 1 pass on to the consideration of particular forms of fever. Sect. I.— The Synochal grade of Idiopathic Fever, or Simple Inflammatory Fever; Febris Irritativa; Pyrexia Sthenica; Febris Vasorum; Inflammatoria; Enechia Cauma. This variety of continued fever is attended with the highest grade of febrile excitement, associated with increased irritability, as well as increased power of action in the heart and arteries. The premo- nitory stage is always short, the fever coming on suddenly with dis- tinct chills or rigors, the febrile action is rapidly developed, the whole surface becoming speedily intensely hot,* the pulse full and vigor- * The heat of the skin is of the kind usually called burning, in contradistinc- tion to that peculiar biting or acrid heat which occurs in typhus fevers, termed calor mordax. By laying the hand on the skin of a patient labouring under inflam- matory fever, the sensation of heat communicated is at first very considerable, but on suffering the hand to remain for a short time, the sensation of heat gradually diminishes, until it seems to the touch but little above the natural temperature of the body. In typhus, on the contrary, the longer the hand is suffered to be in con- tact with the patient's body; the more pungent and perceptible does the heat (calor 158 SYNOCHA, OR ous, and rarely above one hundred and twelve in a minute, the face flushed and turgid, the eyes suffused, sparkling, and unusually sensible to the light, the temples and carotids throbbing, the head painful, the mouth and throat very dry, the breathing oppressed and hurried, the thirst for cold water very urgent, the tongue covered with a white fur, the bowels torpid, the urine very high-coloured, and small in quan- tity, the skin dry, harsh and suffused with a slight blush, and the ears morbidly sensible to sounds. Delirium is not a usual occurrence in this variety of fever; but when it does supervene it generally be- comes extremely violent, and greatly increases the unfavourableness of the case from its dependence, generally, on cerebral inflammation. The blood, when drawn, exhibits the inflammatory character already mentioned, i. e., the buffy coat,* cupped crassamentum, a paucity of serum, &c. These symptoms usually suffer regular remissions and exacerba- tions ; the former occurring in the morning, and the latter in the evening, until they finally terminate entirely under some critical eva- cuation. Simple synocha, or inflammatory fever, very rarely con- tinues beyond the ninth day, and still more rarely beyond the four- teenth, and not unfrequently terminates its course as early as the fifth or seventh day. When the termination occurs about the seventh day, the symptoms usually go on increasing in violence to the fourth or fifth day; and when the disease is prolonged to the fourteenth day, the increase generally continues to the ninth, or perhaps the eleventh day. The resolution of inflammatory fever is almost invariably accom- panied by general and free perspiration, together with its never-fail- ing concomitant, a reddish or pale sediment in the urine. In some instances, a slight hemorrhage, particularly from the nose, accom- panies the crisis. In general, these critical discharges take place a few hours after an evening exacerbation, and this exacerbation is often ushered in by a slight chill. •Inflammatory fever does not, however, often continue its course throughout in the regular and simple form which has just been de- scribed. Topical inflammations, of more or less intensity, very sel- dom remain wholly absent in the progress of the disease. The human system is rarely in such a condition as that some organ or structure is not in a state of predisposition to inflammation; and there can scarcely be a circumstance better calculated to produce inflammation in a part thus predisposed than the very greatly augmented momen- tum and peculiar condition of the blood which exist in this variety of fever. When local inflammation supervenes in the course of a mordax) become, and the biting or acrid sensation of heat remains in the hand even after it is removed from the patient. * The buffy coat, which occurs in inflammatory fevers, differs from a some- what similar appearance observed sometimes on the blood of typhus patients. The former is of a uniform yellowish colour, and very tenacious whereas the latter is brittle, of a paler yellow, and presents an iridescent appearance reflect- ing some of the colours of the rainbow when held in certain positions to the light. SIMPLE INFLAMMATORY FEVER. 159 simple synochal fever, the general aspect and disposition of the dis- ease will, of course, be considerably altered. Sometimes the brain and its meninges become inflamed, at an early period of the disease ; but this occurrence is much less common in the synochal than in the synochus and typhus grades of idiopathic fever. Occasionally syno- chal fever, after having continued for a day or two, becomes compli- cated with rheumatic inflammation; and in some instances inflam- mation occurs in one or more of the thoracic or abdominal organs. In general, the more the brain becomes affected, either by inflamma- tion or sympathetic irritation, the more apt will the system be to sink into a state of prostration or oppression. When the febrile reaction is extremely vehement, or the system habitually delicate and feeble, simple inflammatory fever sometimes exhausts the vital energies, and passes into a low or typhoid state. The constitutional predisposition to synochal fever would seem to consist in a vigorous condition of the vital powers, robust health, activity of the digestive and nutritive functions, and an irritable ple- thoric habit. Persons between the fifteenth and fortieth year of age, of a sanguineo-athletic temperament, appear to be most liable to fever of this vehement character. In early infancy, and in old age, simple inflammatory fever is not so often found to occur as during the intermediate periods of life. Causes.—The exciting causes of inflammatory fever are very various. This grade of fever may be produced by cold, atmospheric vicissitudes, high solar heat, the intemperate use of spirituous liquors, too free an indulgence in high-seasoned and irritating articles of food, the sudden suppression of natural or habitual evacuations, excessive corporeal exertions, a draught of cold water when the body is heated by exercise, violent passions, mechanical injuries, &c. Of all these causes of synochal fever, however, cold is by far the most common. It is from the extensive influence of this febrific cause that continued fevers of a synochal grade are so common in cold and variable climates, and during the cold and changeable months of spring and autumn in the temperate latitudes. During the sum- mer months we seldom meet with general fevers of a very phlogistic character; and pure synochal fevers are perhaps still less common in the intertropical climates. Prevailing northwest and northeast winds are particularly favourable to the occurrence of inflammatory fevers. So remarkably is this the case, that typhus fevers will sometimes as- sume, for a time, a decidedly phlogistic character, if the wind shift suddenly from a southern to a northern point. May not the electric changes of the atmosphere have some agency in the production of this effect ? From the influence which atmospheric vicissitudes and sudden variations in the direction of prevailing winds are sometimes found to have on patients and convalescents confined in close cham- bers, or even in bed, this supposition does not seem to be improbable. There are, indeed, some writers who contend that a superabundance of electricity in the atmosphere constitutes the cause of epidemic in- flammatory fevers. Hopf observes, that fevers of this kind are always most apt to prevail during those seasons and meteorological conditions, 160 SYNOCHA, &C when the atmosphere is most charged with the electric fl uid. Red thinks that electricity often contributes considerably to the production of phlogistic fevers by increasing the general irritability of the system.* It may be observed, however, that the grade or modification of a fever does not depend so much on the character of the remote or ex- citing cause, as upon the peculiar condition of the animal system at the time the cause exerts its morbific influence. Thus, the same de- gree of cold may produce a low or typhoid fever in one, and a vehe- ment inflammatory fever in another individual—a circumstance which proves unequivocally that such diversities depend mainly, and often wholly, on the peculiar predisposing condition of the body itself. If of two individuals seized with fever from the same atmo- spheric vicissitude, one be especially prone to inflammation of the brain or of the mucous membrane of the alimentary canal, and the other to inflammation of the fibrous and serous structures, or be wholly free from any local predispositions of this kind, the fever will most probably early assume a low or typhoid grade of vascular re- action in the first, whilst in the latter it will be apt to retain its vigor- ous synochal character throughout its course. When speaking of the general character and etiology of fever, I observed that in simple inflammatory or synochal fever, the principal febrific irritation is, probably, located in the vascular system—that is, in the internal membrane of the heart, arteries, and capillaries. In those general inflammatory fevers which arise from the influence of cold, at least, this is probably the case ; for, in instances of this kind, besides the internal congestions and inequilibrium of excitement re- sulting directly from the impressions of this cause, a large proportion of the recrementitious elements of perspirable matter must remain mingled with the blood, (unless speedily removed by the vicarious action of some other emunctory,) and necessarily impart to this fluid qualities which are not natural to it. Most assuredly the retention of materials which have become useless to the system, and for whose constant elimination nature has provided so extensive a series of emunctories as the cutaneous exhalents, cannot be long tolerated by the animal economy with entire impunity. The blood is the natural stimulant of the sanguiferous vessels, and we must believe that its stimulating qualities are naturally in due and harmonious relation with the sensibility and irritability of its appropriate vessels. When, therefore, in consequence of suppressed perspiration, this fluid be- comes surcharged with the elements of recrementitious perspirable matter, its natural relations with the heart, arteries, and capillaries will be destroyed, and irritation more or less intense must almost necessarily ensue. Why such a cause should produce typhoid fever in one, sy- nochus in another, and pure synocha in a third individual, we may not be able to ascertain; but the grade of fever is, no doubt, deter- * Hopf, Dissertat. sistens rudimenta theor. de principio febres inflam. epidemica gignente. Reil, iiber die erkentniss und kur dur Fieber. Band. i. s. 501. See also Gautier's work, entitled Commentatio medica de irritabilitatis notione natura et morb. p. 21. COMMON CONTINUED SYNOCHUS FEVER. 161 mined by the particular condition of the system in relation to acci- dental or habitual debility, local disorder or predisposition, tempera- ment, modes of living—in short, every thing which constitutes a deviation from perfect health. That the degree in which'the sensorium commune becomes impli- cated/has an important share in determining the grade .of febrile re- action, has already been observed in several places. It would, indeed, seem very reasonable to conclude, that as the powers of the system depend mainly on the regular supply of the nervous influence, the more the brain, its fountain, becomes involved in disease, the feebler will be the powers of the vascular and muscular systems. All low or typhoid fevers, in truth, are characterized by early and conspicuous manifestations of cerebral disturbance, and the prostration and ence- phalic disorder generally increase, pari passu. In fevers of the sy- nochal grade, on the contrary, the brain and nerves suffer but little ; and, when inflammation of the brain does supervene, the system and vascular reaction soon sink to a lower grade. The prognosis in simple inflammatory fever is, in general, favoura- ble. This, indeed, may be regarded as the least dangerous of all the varieties of continued fever, so long as it retains its simple form. When local inflammation supervenes, the danger will be more or less increased, according to the importance of the organ or structure in which the inflammation occurs, or the variety and force of its sympa- thetic connections, and according also to the intensity of the inflam- mation. When the breathing is free, and without cough or pain in the chest, and the abdomen neither tender nor tense to the touch, we may conclude that the fever is not of a dangerous character, from the almost certain absence of thoracic and abdominal inflammations. Slight delirium during the exacerbations is not to be considered as a very unfavourable symptom; when it becomes very violent, however, it betokens encephalic inflammation; and, of course, is indicative of greatly increased danger. Richter says, that a very profuse discharge of limpid urine, occurring suddenly; liquid or watery discharges from the bowels ; and very copious sweats without sedimentous urine and abatement of the symptoms, constitute very unfavourable signs in synochal fever. The signs which announce a favourable change aire, the occurrence of slight hemorrhage from the nose; general perspiration, attended with pale urine, becoming turbid when cool; and diminution in the frequency, hardness and activity of the pulse, and in the febrile tem- perature of the surface. Sect. II.— The Synochus grade of Idiopathic Fever. Common Continued Synochus Fever (Synochus Simplex). The ordinary continued fevers, those which are most frequently encountered in practice, though phlogistic in their character, do not manifest that intense grade of inflammatory excitement and perma- nency of vital resistance which characterize the variety of fever de- VOL. I.—11 162 COMMON CONTINUED scribed in the preceding section. In the simple continued fevers which form the subject of the present section, there exists, as in pure synocha, strong febrile reaction; but the vital powers are not suffi- ciently sustained to enable them to maintain this elevated and ener- getic grade of morbid excitement—and hence, although the fever may commence with a degree of vascular reaction and general strength differing but very little from synocha, yet, both the grade of febrile excitement and the general powers of life will soon decrease con- spicuously, and verge to the low or typhoid state. The principal sources of this modification of continued fever are, cold or atmospheric vicissitudes, and irritation or disorder of the ali- mentary canal and of the biliary organs. Cold, however, is decidedly the most common source of the ordinary continued fevers of the tem- perate and more northern latitudes. When the disease arises from this cause, it is generally more phlogistic in its early periods, than when it occurs as the consequence of gastro-intestinal disorder or other febrific circumstances. The status gastricus of the German pathologists is, nevertheless, almost invariably present in every modi- fication of continued fever of the synochus grade. An early occur- rence of nausea, vomiting, foul tongue and disagreeable gastric sen- sations, are among the most frequent symptoms of common continued fevers. In this respect, common continued fever of the synochus grade differs from synocha or pure inflammatory fever; the latter being but rarely attended by very manifest signs of gastric disturb- ance. Simple continued synochus fever occurs under various modifica- tions, many of which have been described by authors as distinct varieties of fever. The ordinary continued fevers of our cold and variable seasons, depending on the febrific influence of low tempe- rature or sudden atmospheric vicissitudes, occur under various grades of violence from the simple febrile state called a cold, to the most aggravated fever tending rapidly to cerebral oppression and fatal col- lapse. In the mildest modification, a slight and transient feeling of chil- liness is succeeded by a moderate increase of heat on the surface; a white tongue; some increase in the frequency, quickness and full- ness of the pulse; corporeal and mental languor; dryness of the skin; more or less pain over the eyebrows; a red and slightly diminished urine; slowness of the bowels, and disturbed sleep. In some instances, the appetite is but little impaired, but most commonly it is suppressed. This grade of fever generally passes off in a few days, under a gentle perspiration or moderate diarrhoea. The modification, however, which is especially designated by the name of common continued fever, is by no means so mild in its symp- toms or so transient in its duration, and may be considered, in its more aggravated character, as one of the most formidable of general febrile maladies. This modification of the disease is generally ushered in by a distinct cold stage, characterized by great lassitude, restless- ness, a feeling of tension and confusion in the brain, oppressed and anxious breathing, feebleness and quickness of pulse, a clammy SYNOCHUS FEVER. 163 tongue, disgust for food, flatulency and frequently nausea, retching, or vomiting. This stage, alternating towards its conclusion with flushes of heat, often continues for many hours before the stage of excitement is fully developed. The skin now becomes hot, dry, and suffused with a uniform, but slight tint of red; the pulse more fre- quent, full and active ; the face flushed; a dull, heavy, or throbbing pain is experienced in the head; the patient is restless, morose, or peevish, and feels unable to fix his attention, or to exert his mental faculties; his tongue is at first white, becoming dry, harsh, and dark brown as the disease advances; the urine is generally red, sometimes pale, and wholly without sediment; the bowels are torpid, and the alvine discharges soft, and often of a clay-coloured appearance. There is, generally, from the beginning, some degree of intolerance of light and sound, and the carotids and temporal arteries usually beat strongly. These symptoms commonly go on for five or six days without any material changes, except the slight remissions and exa- cerbations which occur in the morning and during the night. Slight delirium commonly occurs during the night for the first five or six days; as the disease continues, however, the symptoms of cerebral disorder become more and more conspicuous, so that, by the eighth or ninth day, it arrives at its acme, and either gradually declines under a favourable crisis, or passes more or less rapidly into a ty- phous condition or collapse, attended with almost constant delirium, partial stupor, dilated pupils, dry, foul and dark--brown tongue, sordes about the teeth, hurried breathing, subsultus tendinum, picking at the bed-clothes; the pulse becoming progressively weaker, smaller and more frequent, and the vital energies sinking more and more until death takes place about the fifteenth, or perhaps the seventeenth day, and sometimes not until a later period, In some instances of common continued fever, the symptoms of cerebral irritation are considerable at an early period of the disease, and the nervous or typhous stage supervenes rapidly and under a highly aggravated train of phenomena. With the development of the stage of excitement, which comes on slowly after a protracted and oppressive cold stage, strong manifestations of a cerebral disorder ensue. The patient evinces great aversion to light and sound; he is tormented by uninterrupted watchfulness; his mind is greatly com fused; delirium comes on early, and soon becomes continuous and often violent; the countenance is flushed ; the carotids beat strongly; the vital and voluntary powers are oppressed; the skin is intensely hot; the whole surface of the body is frequently tender or sore to the touch, and transient darting pains are often experienced in various parts of the body. "An extreme irritability of the nervous system attends the development of the fever; the arms are tossed to and fro on the bed; the head is moved from side to side, and the position of the lower extremities frequently changed."* Flatulency and irri- tability of the stomach, with more or less of tenderness to pressure in the epigastrium, are rarely absent. The pulse is at first frequent * Armstrong on Typhus. American edition, p. 236. 164 COMMON CONTINUED and active, but seldom very firm or tense. The typhous state gene- rally comes on as early as the fourth or fifth day, and in some instances much sooner. When this happens, the pulse becomes smaller and more frequent; the previous high delirium passes into a low muttering raving, and, finally, into a completely oppressed state of the sensorium, tending rapidly to a general prostration of the vital powers. The patient now lies on his back; moans, with his mouth open, and the eyes turned up under the lids. The retina seems insensible to light; one eye appears smaller than the other, from paralysis of one of the upper lids; the muscles of the face are variously agitated; the pulse becomes extremely rapid and small; and a clammy but warm sweat breaks out. The extremities finally become cold, the urine and feeces are discharged involuntarily, and life ceases either gradually or suddenly in a paroxysm of convulsions. Dr. Armstrong very truly observes, that in this latter and aggra- vated modification of the disease, acute or subacute inflammation of the brain is unequivocally present " soon after the full emergement of the fever." He has not, however, paid sufficient attention to the same condition of the alimentary canal. In the early period, and even before the stage of excitement ensues, nausea, retching or vomiting, total disgust for food, and various other disagreeable sen- sations in the abdomen are scarcely ever absent; and in the more advanced stages, tenderness or soreness on abdominal pressure, a tympanitic state of the bowels, a foul tongue, with red edges, indicate with sufficient certainty the presence of gastro-intestinal phlogosis. In some cases, subacute inflammation is developed in the respiratory passages, and occasionally also in other parts of the body, according to the accidental local predispositions which may exist. There are some other modifications of continued fever of the syno- chus grade, which it will be proper to notice in this place. When cold acts on a system which has been previously much under the influence of koino-miasmata, it will sometimes give rise to con- tinued fevers of a manifestly bilious, or what has been called gastric character. Lassitude, a feeling of weight, tension, and dull pain in the head, depraved or obliterated appetite, acid or bitter eructations, a sense of fullness and weight in the stomach and right hypochon- drium, a sallow or icterode countenance, a gloomy taciturn disposi- tion of the mind, transient pains in the abdomen, constipation, or bilious diarrhoea, with occasional slight creeping chills, are the phe- nomena which usually usher in the febrile attack. The heat of the skin rarely becomes very intense; the pulse is full, wavering, active, but very compressible, and seldom above 112 during the first few days of the fever; the tunica albuginea is tinged with bile, and in the progress of the disease a more or less icterode hue extends over the whole surface of the body. The skin is frequently moist about the heart and breast, but general or uniform perspiration hardly ever occurs before the resolution of the fever. The tongue is bitter, and covered with a thick yellowish slime, generally moist at first, but dry. rough, and dark brown in the latter stage of the malady. The urine is highly charged with bile and small in quantity. Nausea, SYNOCHUS FEVER. 165 retching and vomiting always occur, and the patient loathes all kinds of food; the desire for cool and acidulated drinks is generally urgent. The breathing is oppressed, and a short humid cough usually attends; its course, is seldom very protracted, but its tendency to the typhous state is almost always exhibited at an early period, and unless the disease be mild, or speedily subdued, delirium, with the whole train of nervous symptoms mentioned above, and great prostration super- vene by the fifth, seventh, or, at farthest, the ninth day. The remis- sions and exacerbations are always very conspicuous. There is still another modification of continued fever of the syno- chus grade, which arises from the united influence of a damp and cold air, deficient, innutritious, depraved and aqueous diet, mental depression, &c. The premonitory stage is long, but the fever itself varies in duration from five or six days to so many weeks. The pulse is often nearly natural in point of fullness and activity, but generally somewhat accelerated; the thirst is moderate, the appetite weak or entirely lost; the patient is torpid and drowsy; and the eyes are dull and watery; nausea frequently occurs, particularly in the morning; the heat of the surface is considerable; the tongue is white, slimy, and the taste is flat; the urine is pale, crude, and moderate in quantity, and generally surcharged with mucus. As the disease advances the pulse becomes weaker, smaller, and more frequent; delirium of a low muttering kind ensues, with hiccough, subsultus tendinum, and at last coma. The fever does not, however, always run into the nervous state. In some instances a general diaphoresis, and a mucous deposit in the urine, occur about the seventh or ninth day, and leads to a slow convalescence. There is generally more or less tenderness in the abdomen. All the foregoing modifications of continued fevers, but more especially the second, have been confounded with genuine typhus. Dr. Armstrong has pointed out the distinctive characteristics of these maladies, and though he has since changed his sentiments with re- gard to the etiology and essential nature of typhus, the diagnosis which he has given between these two diseases, is nevertheless founded, I think, on sound positions. In typhus the sensorial functions are earlier and more invariably disturbed, and the muscular prostration is greater than in the most common forms of continued fever. Mental depression or despond- ency, a sullen gloom of the countenance, and an almost insurmount- able apathy and disinclination to mental and corporeal exertion, are remarkably characteristic of typhus, and never very conspicuously- present in simple continued fever of the synochus grade. " In com- mon continued fever, the patient generally has not much inaptitude of mind, often answers questions readily, and in a pretty firm voice, without much increased agitation of the breathing; whereas in typhus the answers are mostly given with languid slowness and reluctance, and much speaking obviously disturbs respiration. In common con- tinued fever, the skin is usually of a brighter red than natural ; whilst in genuine typhus it is always more or less of a dusky, dingy colour. In typhus it has an early tendency to become brown and 166 COMMON CONTINUED dry; in the common continued fever it is always white, and often somewhat moist for the first week."* To these may be added the slight exanthematous efflorescence about the fourth day of the stage of excitement in typhus,! which is never seen in common continued synochus; and the very peculiar smelly which exhales from the bodies of typhus patients, and which occurs in no other malady. When common continued fever of the synochus grade remains simple or uncomplicated with manifest local inflammation, it rarely assumes a low or a very dangerous character. Instances, however, do sometimes occur, which apparently, without any local inflamma- tion, continue under no very violent train of symptoms until the vital powers gradually yield, and the system sinks into a state of great de- bility and nervous mobility. These cases are generally prolonged to the fifth, sixth, and even eighth week. The tendency of all febrile diseases, however, is to produce inflammation in some part or other of the system; and in few diseases, perhaps, is this tendency more strongly expressed than in the more violent cases of the present form of fever. Although it cannot be maintained that local inflammation invariably pre-exists as the only immediate cause of that group of phenomena we term fever, it must nevertheless be admitted, that, as an effect, more or less of local inflammation is much more commonly present in febrile diseases than was formerly, and by many is still supposed. In common continued fever from cold, encephalic inflam- mation is by no means a rare occurrence. In the more violent and rapid instances of the disease, where continued delirium, at first furi- ous and then low and muttering, occurs, cerebral inflammation is, no doubt, always present. In nearly all those who die of this form of fever, the brain and its meninges exhibit marks of previous inflam- mation, such as effusion of serum into the ventricles and on the sur- face of the brain, great vascularity of its membranes, redness, vascular turgescence, flakes of effused lymph, &c. Gastro-enteric inflammation, also, is a common occurrence in the severer instances of this variety of fever. Tenderness of the abdo- men to pressure—a constant disposition to lie on the back with the knees drawn up—a red and raw aspect of the edges and tip of the tongue ; intestinal tympanitis, accompanied with low muttering deli- rium, are phenomena very frequently met with in the advanced stage of synochus fever—phenomena which give unequivocal evi- dence of the presence of inflammation in the alimentary canal. In many cases, both the brain and mucous membrane of the intestinal tube are inflamed; and this concomitance of cerebral and intestinal inflammation renders the disease in the highest degree unmanagea- ble and dangerous. Not unfrequently, however, the brain is the only organ which suffers inflammation. When the cerebral affection is unaccompanied by gastro-intestinal inflammation, the patient seldom sinks so rapidly into the typhoid state as when the fever is attended * Armstrong on Typhus, p. 261, first American edition. t Hildebrand on Contagious Typhus. % An Essay on Typhus Fever, by Nafhaif Smith, M. D.; p. 26. SYNOCHUS FEVER. 167 by both these local affections. Great prostration and conspicuous typhous symptoms, in common continued fever, are almost always associated with the above-named signs of gastro-enteric inflammation. The mucous membrane of the respiratory organs, too, generally suffers irritation or some degree of inflammation. More or less cough occurs in the majority of cases; and in some instances the pectoral oppression and difficulty of respiration from this cause become a prominent and serious affection. Prognosis.—When symptoms of local inflammation do not super- vene, the disease generally yields to a moderately antiphlogistic treat- ment, and terminates favourably under a critical diaphoresis within the first two weeks. Early and violent symptoms of cerebral disor- der are indicative of much danger. Continued, low muttering deli- rium, picking at the bed-clothes, paralysis of one or both of the upper eyelids, continued agitation and distortion of the muscles of the face, eyes turned up under the lids, &c, betoken cerebral inflammation, and the utmost degree of danger. Great muscular prostration—constant position on the back—a small, extremely frequent and weak pulse, denote a state of collapse, from which recovery is extremely rare, especially when connected, as it almost invariably is, with manifestations of local inflammation. Ten- derness in the abdomen—a gurgling noise when fluids are swallowed —tympanitis, liquid and unnatural alvine discharges in the early periods of the disease, are always indicative of great danger. Treatment.—In the treatment of simple continued fever, whether of the synocha or synochus grade of febrile excitement, we have the following general indications to direct us in our remedial efforts. 1. To diminish the general momentum of the circulation. 2. Tore- store the natural actions of the various secretory organs—above all, those of the skin, liver, and kidneys. 3. To equalize the circulation and obviate local determinations. 4. To remove from and out of the system, as far as may be practicable, every thing which has a tend- ency to irritate or unduly excite the system. Of these general indications, the first is, undoubtedly, of paramount importance, and should, therefore, always receive the earliest atten- tion in fevers of high vascular excitement. This is, more especially, requisite in pure inflammatory or synochal fever; for here almost every thing depends on the speedy reduction of the excessive arterial reaction. Blood-letting stands at the head of our means for reducing vascular action, or inordinate momentum of the circulation. What- ever may be the immediate cause of the increased action of the heart and arteries, there can be no safe measure which will so speedily and effectually diminish its violence as the abstraction of a portion of the circulating fluid. In order to obtain the full advantages which blood- letting is capable of affording in febrile diseases, it ought to be em- ployed to the extent of producing a decisive impression on the system in the early period of the malady. Blood may, indeed, be drawn with benefit at any period of the disease, provided the pulse be active, quick, dense or hard; but one decisive bleeding soon after the febrile excitement is developed, will generally do more towards subduing 168 COMMON CONTINUED the violence, or shortening the'duration of the malady, than a much greater quantity of bloOd taken away at four or five less efficient bleedings practised at intervals throughout its course. In truth, the benefit derived from blood-letting does not depend so much on the quantity of blood abstracted, asuponthe degree of impression made on the system by the evacuation; and hence, 20 ounces taken at once will often do more good than double this quantity taken in small but repeated bleedings. " In venesection forthe relief of an inflam- matory affection, our object is not simply to diminish the quantity of the blood, but also to diminish the action of the heart and arteries; and it may be affirmed that twelve ounces of blood drawn from a large orifice so rapidly as to produce an immediate and decided effect on the pulse, will prove much more useful than a considerably larger quantity taken so slowly that the heart has time to accommodate itself to the loss," and thus to resist the subduing influence of this mea- sure.* It is certainly a good rule in practice to accomplish our intentions with as little expenditure of theresources of the system as possible. In all inflammatory affections, therefore, the blood ought to be drawn in a futl stream and from a large orifice, and suffered to flow until its influence on the system is unequivocally manifested in the sub- 'dued action of the heart and arteries, and the feelings of approaching syncope. This rule is particularly important in the acute p'hlegma- sial affections. By taking away the blood in this manner, we obtain a more decisive and permanent reduction of the phlogistic excite- ment, and with a smaller expenditure of the blood than when the evacuation is less rapidly and efficiently made; since in this latter case it must generally be frequently repeated before the desired re- duction of the vascular reaction is effected. There is another cir- cumstance which renders very efficient blood-letting in the onset of febrile diseases preferable to less decisive but repeated abstractions of blood. However much the system may be subdued by a copious bleeding in the commencement of a fever, the vital energies soon rally sufficiently to prevent dangerous prostration from this measure; but when the blood, though not copiously at a time, is frequently drawn, it happens, sometimes, that at last the system is suddenly prostrated into a state of collapse, out of which the most potent stimu- lants will hardly suffice to raise the patient. I remember, with pain, the unfortunate lot of an amiable and intelligent friend. He was a man of a healthy constitution, and fond of indulging in the pleasures of the table. He was seized with a simple synochal fever from cold. His physician bled moderately; the fever went on unchecked; he bled again and again daily; after the seventh bleeding there was still too much quickness and tension in the pulse ; the lancet was inserted the eighth time, and the patient almost immediately sunk into a state of collapse. Stimulants, both external and internal, the most diffusive and potent, were now diligently applied, but all in vain ; he lived but a few hours longer. Scudamore on the Blood. SYNOCHUS FEVER. 169 In fevers of the synochal or highly phlogistic grade, almost every thing depends on the speedy reduction of the excessive vascular ex- citement. Prompt and decisive blood-letting is indispensable in fevers of this kind. In the ordinary continued fevers of a less vigour- ous character, or the synochus grade where local inflammation has not already supervened, it is not often necessary to draw much blood. One or two bleedings, to the extent of making an evident impression on the system, will generally moderate the arterial action sufficiently; and in the milder instances of the disease, blood-letting may sometimes be wholly dispensed with. As the principal danger, however, in fevers of this kind, depends on the supervention of local inflammation, and as this is by no means an uncommon occurrence, even in fevers which at first appear to be mild, it is always best to moderate the general momentum of the circulation at once, by an adequate bleeding in the commencement, in order to lessen, as much as may be in our power, the liability to visceral inflammation. In the treatment of every form of fever, the prevention, or the speedy removal of local inflammation, constitutes a chief object of reme- dial attention; and there is no general remedy, which answers this object more directly than the judicious employment of the lancet. In the employment of blood-letting the pulse must be our prin- cipal guide. The quantity and frequency of the bleeedings must be regulated chiefly by the state of the pulse, and particularly by the effects produced on it by the evacuation. There are, however, various other circumstances, which it is of much importance to bring into view, in the judicious management of this remedy. The tem- perament of the patient, the age, sex, constitutional predisposition, mode of living, climate, habits, &c, all claim especial attention. A native of an intertropical country will, cseteris paribus, rarely bear the same extent of depletion as an inhabitant of a northern climate. Persons of a nervous or relaxed habit of body, sink much sooner from the loss of blood than the sanguineous and athletic. In very old people we must proceed with more caution in the use of the lan- cet than in the youthful and middle-aged; nor can we in general take as much blood without detriment from the luxurious, indolent, and intemperate, as from the vigorous, active, laborious, and tempe- rate. The inflammatory or buffy coat of the blood may, in general, be regarded as an indication for the further employment of the lancet. It is not, however, to be implicitly relied on as a guide in this respect. In rheumatic fever, for instance, the blood will often continue to ex- hibit the buff after bleeding has been practised to the utmost allow- able extent. Nor are we to regard the disappearance of this pheno- menon after several bleedings, as an objection to the further use of the lancet, if the pulse continues to indicate its propriety. A hard, tense, or quick and corded pulse, will always justify the use of the lancet, whatever may be the general character of the dis- ease, or at whatever period of its course it may occur. In the com- mencement or early period of the disease, the blood should be suffered to flow until a strong impression is made on the system; but when 170 COMMON CONTINUED bleeding is practised at an advanced stage of the fever, it will, in general, be most prudent to carry it to the extent of producing only a slight effect on the pulse, as a very decided impression might rea- dily precipitate the system into a fatal collapse, or at least dangerous prostration. . As the bowels are almost invariably more or less constipated in the varieties of fever under consideration, and liable, therefore, to irritation from this source, they ought always to be early evacuated by suitable purgatives. Without doubt, the secretions which flow into the intestinal canal, in every variety of fever, become additional sources of irritation when suffered to accumulate; and hence, simply with the view of removing these accidental supporters of febrile ex- citement, purgatives are important remedies throughout the whole course of acute diseases. In synochal and the common continued fevers, however, purgatives are beneficial, not only by evacuating the irritating contents of the bowels, but in some degree also by their depletory and revulsive effects. The choice of the purgatives is by no means a matter of indifference in the treatment of the present variety of fevers. The saline purgatives are generally preferable on account of the usual mildness of their operation, and their tendency to allay febrile excitement, by their general refrigerant influence, independently of their evacuant effects. The sulphates of soda and magnesia are excellent aperients in fevers of a highly phlogistic cha- racter. They may be administered with peculiar advantage, accord- ing to the following formula: K.—Sulphat. sodae vel magnes. ^ii. Tart, antimon. gr. i. Solve in aquae fontanae %x. M. ft. Of this solution a wineglassful may be taken every hour, until purging is produced. In the commencement of the fever, when there is reason to appre- hend the early occurrence of serious cerebral affection, a mixture of jalap and cream of tartar is an excellent purgative. Twenty grains of the former, with two scruples of the latter article, may be admi- nistered for this purpose. This mixture generally causes very copious serous stools, and thus acts at once as a strong revulsive upon the brain, and as an active depletory measure. In those.cases of continued fever which are attended with manifest derangement of the biliary organs, six or eight grains of calomel should be exhibited a few hours before the saline purgative is admi- nistered. Cremor tartar dissolved in tamarind water, or the SekU litz powders, constitute very excellent laxatives in inflammatory fevers, after the bowels have been once well evacuated by a more active purge. Useful, however, as purgatives most certainly are, in fevers of the character now under consideration, they may, nevertheless be as readily abused in the present, as in other forms of fever. Harsh, drastic, or very frequently repeated catharsis, seldom fails to do much injury by exciting great irritation or subacute inflammation in the mucous membrane of the alimentary canal, and, perhaps, also in SYNOCHUS FEVER. 171 some degree, by disturbing the natural tendency of these fevers to terminate by a critical discharge from the cutaneous exhalents. After the first purge, which ought to be sufficiently active to evacuate the bowels well, the milder laxatives alone should be employed in such a way as to procure two or three gentle evacuations daily. These observations are made in reference to simple or general inflamma- tory or synochus fever; for, in many of the most dangerous phleg- masial diseases, very active purgatives are often decidedly beneficial by their revulsive effects, as well as by their tendency to moderate general febrile excitement. Thus, in arachnitis, in peritonitis, in acute ophthalmia, &c, active cathartics often contribute very materially to the reduction of the malady. Diaphoretics are well calculated to do good in fevers of a high grade of excitement. Torpor of the cutaneous exhalents is generally the first link in the chain of morbid actions which take place in the development of these maladies, and continues often throughout the greater part of their course, unless overcome by the employment of suitable diaphoretics. In vain will we look for the subsidence of such a fever, so long as this important emunctory remains inactive. The benefits which accrue from this class of remedies are, however, by no means proportionate to the copiousness of the evacuation they produce; for in almost every variety of continued fever, much more advantage usually results from a moderate and uniformly diffused diaphoresis, than from very profuse sweating. In the early period of inflammatory fever, it is generally extremely difficult, and often impossible, to procure more than a very partial and transient diapho- resis. Nevertheless, the remedies which are commonly employed to produce diaphoresis, possess the power of moderating febrile ex- citement, independent, apparently, of any evacuant effect; and hence, although we may fail in procuring an adequate discharge by the skin, considerable benefit will generally arise from the early and regular employment of such medicines. Nitre, which is one of our most valuable diaphoretics in inflammatory fevers, manifests also no in- considerable power in reducing the general phlogistic condition of the system. The same is still more conspicuously the case with antimony, and these two articles are accordingly almost universally employed in fevers of a phlogistic diathesis. Nitre and tart, anti- monii, are usually administered in combination, in doses of from ten to fifteen grains of the former, to one-eighth or one-tenth of the latter, every two or three hours. This combination, however, sometimes acts strongly on the bowels, and gives rise to irritation, tormina, and frequent watery stools. Such effects tend greatly to increase the vio- lence and danger of the disease, and must be speedily counteracted by mucilaginous drinks, and minute doses of calomel and ipecacu- anha. Thus: R.—Calomel, gr, i. Pulv. ipecac, gr. vii.—M. Divide into eight equal parts, of which one is to be taken every half hour or hour. This combination, when aided by mucilaginous diluents, seldom 172 COMMON CONTINUED fails to subdue the gastro-intestinal irritation produced by irritating remedies or other offensive ingesta. This is a point to which great attention should be constantly paid. The exhibition of nitre and antimony or cathartics, after the effects just mentioned occur, is ex- ceedingly improper, as it must almost inevitably increase the violence and dangerousness of the malady. It should always be recollected that the chief danger in fevers of this kind arises from the local in- flammations which are so apt to occur; and our main object should be to prevent the occurrence of inflammation, or to subdue it as speedily as possible. I have usually preferred administering the nitre and tart, anti- monii, according to this formula, as being much less apt, I think, to irritate the stomach and bowels, than when given in the form of a powder. R.—Nitrat. potassae 5pj. Tart, antimonii gr. i. P. extract, glycyrrh. gij. Mucilag. g. arab. ^ss. Aquae fceniculi. Aq. fontanae aa giv.—M. ft. Dose—a tablespoonful every hour or two. Cullen was of opinion that the antiphlogistic effect of tart, anti- monii depends on the nausea, and consequent relaxation which it produces when taken in full doses; but this opinion has not been confirmed by experience ; it being now very generally admitted that it possesses a sedative or contra-stimulant power, wholly inde- pendent either of an evacuant or nauseating effect. Of late this arti- cle has been much employed by Rasori and his followers as a contra- stimulant, in what may well be called enormous doses. It is asserted that when given in large and frequent doses, to the extent of from twenty to thirty grains daily, it rarely produces emesis,and often not even nausea, but greatly diminishes the action of the heart and arte- ries, and general as well as local inflammatory action. In Italy the most violent inflammatory fevers are treated, and according to the published reports with success, by large and frequently repeated doses of this article, without any direct depletion whatever. Of this practice I can say nothing from my own experience. That it may be adequate to subdue inflammatory excitement can scarcely be doubted, but neither its safety nor its successfulness appears to me such, as to warrant the relinquishment of depletion, with the usual antiphlogistic auxiliaries in favour of its exclusive employment. In small doses antimony is a safe and an important medicine in the treat- ment of inflammatory fevers. From one-eighth to one-tenth of a grain every hour or two, will generally contribute materially to the reduction of febrile reaction, and rarely fail ultimately to excite the cutaneous emunctories. I have been led to believe that the diapho- retic and antiphlogistic effects of this antimonial are more certainly and conspicuously displayed when administered in a considerable por- tion of some bland nutritive or mucilaginous fluid, than when given in the form of powder, or an ordinary aqueous solution. One grain SYNOCHUS FEVER. 173 of tart, antimonii may be dissolved in a pint of barley water, and drank in the course of four or five hours. Antimony must be used very cautiously, however, in cases attended with symptoms of gastric irritability or irritation. Its salutary powers are most conspicuously displayed in the pure synochal fevers, although more or less benefit may be derived from its judicious employment in every modification of fever attended with an increased momentum of the circulation and a dry and preternaturally warm skin. James's powder, in small and repeated doses, is also an excellent antiphlogistic diaphoretic, in fevers of this kind. It may be given by itself, or in union with nitre, in doses of half a grain of the former with twelve grains of the latter, every two hours. Of all the seda- tive diaphoretic remedies I have yet employed, the most powerful is a liquid antimonial preparation, somewhat similar to the old dia- phoretic antimony in its composition, prepared by Mr. Edward Evans, an apothecary of this city. This preparation is but little known, although, from what I have frequently witnessed of its effects, I am fully satisfied that it is a peculiarly valuable remedy. Mr. Evans is the only person in this country who prepares this antimonial remedy, and no measures whatever have been taken by him, or by any one else, to bring it into notice. Digitalis in small and frequent doses, either alone or in combina- tion with nitre, will sometimes aid considerably in reducing excessive vascular action. From a quarter to half a grain, administered every two hours, rarely fails to make some impression on the pulse, in the course of forty-eight hours. It is particularly appropriate in those instances where, after due depletion and catharsis, the pulse remains quick, somewhat active and frequent, and where it may be doubted whether more blood may yet be prudently abstracted. Mercury is not applicable to the treatment of simple inflamma- tory fever. In common continued fevers of a less violent grade, especially in instances attended with biliary disorders, and in cases which become complicated in their course with subacute visceral inflammation, the mercurial influence will frequently afford important advantages. In no case, however, ought mercury to be administered with a view to its constitutional influence, before the general mo- mentum of the circulation has been considerably diminished by bleeding and purging. Where opportune and moderate evacuations, together with blisters, fail to arrest cases of common continued fever, attended with subacute inflammation, "calomel," says Dr. Arm- strong, " should be given as a salivant. On numerous occasions," he affirms, " I have seen an evident improvement in visceral inflam- mations from the time that ptyalism took place. I must again observe, however, that mercury is salutary only in those modifica- tions of continued fever, where the general powers of the system and the action of the heart and arteries evince a tendency to a moderate grade of febrile excitement. Where the vital resistance and actions are vigorous, or where very acute and rapid visceral inflammation is present, nothing but the most prompt and efficient employment of the lancet can afford any reasonable hopes of success. In most 174 COMMON CONTINUED instances of common continued fevers, however, there exists a radi- cal tendency to a typhoid state, and the inflammations which arise are usually of a slow or subacute character. In such cases mercury may be accounted as among our most useful remedies, when pre- ceded by proper depletory measures. It must also be observed^ that mercury can be usefully employed only in the early periods of the disease, anterior to the approach of collapse or cerebral oppression. I have generally preferred giving the calomel in two grain doses, with a few grains of ipecacuanha, every four or five hours, until the gums become slightly affected. I have often found the skin to become moist, the pulse softer and less active, and the symptoms generally to abate, as soon as the mercurial influence became per- ceptible in the gums. There are various other general antiphlogistic remedies of minor importance, which may be occasionally resorted to with advantage in the fevers under consideration. When the disease is in a great measure subdued, and the pulse continues to be somewhat quick, sharp, and irritated, and the skin rather dry and hot, the following mixture will generally act very beneficially: R.—Spirit, mindereri, %\i. Spirit, nit. dulc. giiss. Vin. antimonii, giss. Syrup limonis, ^ij. S. Dose, a tablespoonful every two or three hours. In the early period of simple continued fever, when the skin is very hot and dry, considerable relief may be obtained from spong- ing the body with cool water. In fevers of a very high grade of excitement, a draught of cold water is not only always very grateful to the patient, but tends, moreover, to reduce, for a time, the exces- sive febrile heat, and to dispose to diaphoresis. In cases complicated with local inflammation, however, cold ablutions will rarely do good, and sometimes manifest harm. Cool acidulated drinks ought, indeed, to be freely allowed in synochal fever, so long as the skin remains dry. Lemonade, solutions of tamarinds, currant, black- berry or strawberry-syrups, form very pleasant and useful beverages in febrile affections. When the surface is moist with perspiration, the drinks should be tepid. The mild diaphoretic infusions, such as elder-blossom tea, infusions of eupatorium perfoliatum, balm, marjoram, &c, together with spiritus mindereri, or spirit, nit. dulc, minute portions of tart, antim., or the saline effervescing draught, are appropriate and useful remedies in the latter periods of the dis- ease, when the febrile irritation is about declining under a gentle diaphoresis. Although tropical remedies are not particularly indicated in the treatment of simple or general fevers, yet as synochal and common continued fevers are apt to become complicated, during their progress, with visceral inflammation, local remedies often become indispensable to the safety of the patient. The brain and mucous membrane of the alimentary canal, are most frequently the seats of these secondary SYNOCHUS FEVER. 175 inflammations. In some instances, perhaps in the majority, both these structures become inflamed at once; in others, one of them alone suffers inflammation. The occurrence of cerebral inflammation in common continued fever is always an accident of the most alarm- ing and dangerous character, and ought to be promptly and vigorously counteracted by every efficient means in our power. In the more violent cases of the disease, symptoms of approaching cerebral in- flammation sometimes manifest themselves soon after the full deve- lopment of the fever, but in most instances, the inflammation does not show itself until about the fifth or sixth day of the disease. Where there is reason to apprehend the occurrence of cerebral inflammation, or where it has actually commenced, blood should be at once drawn until syncope approaches, and one or two brisk cathartics admi- nistered. Topical bleeding by leeching, is generally especially recom- mended in such cases; but my own experience leads me to place much more reliance on cold applications to the bare scalp, with blis- ters on the back of the neck, and a few cups to the temples. As leeching, however, does not take up a great deal of time, nor prevent the use of these latter applications, it should undoubtedly be employed if leeches can be had. Whilst these applications are being made to the head, warm fomentations should be applied to the feet and legs, in order to cause as much revulsion from the brain as possible. It ought to be particularly kept in mind, that little or no benefit will be derived from any of these applications so long as the momentum of the general circulation remains preternaturally augmented. General blood-letting, to the extent of producing a very decided impression on the circulation, should always precede the employment of leeching, cupping, or blisters, in fevers of high vascular excitement. From this precept, however, we must except the application of cold, which, in cerebral inflammation especially, may be employed with great benefit, however vigorous the febrile action may be. The applica- tion of ice or iced water to the head, is, indeed, a very valuable remedy in fevers attended with cerebral inflammation. The hair should be cut off close to the scalp, and cold applications almost con- tinually made to the head, at the same time that the circulation is solicited to the inferior extremities by warm or irritating applications to the feet. The common practice in this country, of applying blisters to the scalp, is of very doubtful efficacy. From much attention to this subject I am satisfied that little or no benefit can be derived from the application of blisters to the top of the head in cases of cerebral inflammation.* Applied to the back of the neck, or between the * [This is no doubt true in the active or earlier stages of cerebral inflammation. But after extensive and protracted depletion, no remedy is more efficacious than blisters over the entire shaven scalp. I am confident that several lives have been saved under desperate circumstances by this remedy. I recollect one case where, on the seventh day of acute menigitis, after frequently repeated general and topi- cal blood-letting and severe purgation, the delirium and intolerance of light and sound yielded to a large blister over the scalp, which was left on for nine entire 176 COMMON CONTINUED SYNOCHUS FEVER. shoulders, however, they will often assist materially in reducing en- cephalic inflammation, and should certainly never be neglected in such cases. When the inflammation is seated in the alimentary canal, leeches succeeded by a large blister should be applied to the abdomen ; and nothing but the blandest mucilaginous drinks allowed, with occasional laxative enemata. The usefulness of cold applications is almost wholly confined to encephalic inflammation ; for in gastro-enteritis, they are wholly useless, and calculated rather to do mischief. In- stead of cold, warm fomenting applications ought to be employed in this latter inflammation. It should be observed that the mucous membrane of the intestines is frequently intensely inflamed, without the patient complaining of any pain in the abdomen. Ignorant practitioners never think of in- flammation unless they hear the patient complain of pain. I have known cases of continued synochus fever treated to within a few hours of their fatal termination, without the slightest suspicion, in the mind of the physician, of the existence of intestinal inflammation, because no pain was complained of by the patient, although the ab- domen was exceedingly tender to the touch, and the tip and edges of the tongue clean and florid. In all cases of general fever, it is of the utmost consequence to attend carefully to the state of the internal organs, more especially to that of the gastro-intestinal mucous structure. Firm pressure should from time to time be made on different parts of the abdomen. If the patient complain of much tenderness or pain when pressure is made, there will be reason to apprehend the existence of inflamma- tion ; and if, in addition to this sign, the tip and edges of the tongue are red and clean, the presence of mucous inflammation of the bowels may be deemed certain. Frequently, on examination, the abdomen is found so tender that even slight pressure gives rise to the severest suffering, although, without pressure, the patient does not complain of any pain. In examining the abdomen, care must be taken to press success- ively upon every part of the abdominal parieties. In some instances we may press firmly upon several parts without giving rise to much uneasiness, until we come to the region over the inflamed portion of the bowels, where the slightest touch will cause the patient to flinch or cry out. Even when the patient is incapable of expressing his sensations, from being in a state of delirium or stupor, we may gene- rally detect the presence of abdominal inflammation by watching the countenance while the pressure is made. If there is inflamma- tion, the countenance immediately assumes the expression of pain and suffering, on compressing the abdomen. During the whole course of the present variety of fevers, the strictest attention should days. This patient recovered without any relapse. In another case of acute hydrocephalus in a child attended with complete prostration, coma and dilated pupils, the same remedy, continued for several days, afforded unexpected and complete relief.—Mc] TYPHUS. 177 be paid to the removal and exclusion of every thing which is capable of irritating or unnecessarily exciting the system. In synochal or inflammatory fever, the chamber should be kept quiet, cool, and ob- scure ; and besides the beverages already mentioned, and thin barlev or toast water, no nourishment whatever should be allowed. This is a most important though very often much neglected requisite in the safe remedial management of fevers. The most judicious treat- ment, in other respects, is frequently rendered abortive by a want of proper dietetic regulations. Tonics, or stimulants, are very rarely necessary during convale- scence from inflammatory or common continued fever. They would, indeed, very generally prove prejudicial. For several days after the complete subsidence of the fever, the patient ought to refrain from solid animal food, and above all from high-seasoned articles of diet. Farinaceous liquids, and weak animal broths, taken in moderation, will in general be quite sufficient for the first four or five days of con- valescence. Sect. III.— Typhus. There is, perhaps, no form of febrile disease, concerning which physicians have expressed a greater variety of conflicting opinions, than typhus fever. Long an object of the deepest interest and atten- tion, it might well be presumed, that every circumstance calculated to illustrate its nature and remedial treatment, must have been abun- dantly noticed and accurately estimated. Whatever industry and carefulness of observation may have been bestowed on this subject, the result has not been very flattering, for even at this day, there ex- ists great discrepancy of opinion concerning many of the most im- portant points of its pathology and treatment. Without entering into a detail of the vague and arbitrary employ- ment of the term typhus, in the writings of both ancient and modern physicians, it will be sufficient to state, in limine, that typhus is here regarded as a peculiar form of fever, capable of propagating itself by contagion—commencing often like synochus, and passing into a state, characterized by a stunned or torpid condition of the sensorial powers, with great prostration of strength and delirium. Symptoms. — (Premonitory stage.)—A peculiar uneasy sensation in the pit of the stomach, want of appetite, slight giddiness and nau- sea, pale, shrunk, and dejected countenance, dull and heavy eyes, often tremor of the hands, and a general feeling of weariness, debi- lity, and disinclination to mental and corporeal action. These premo- nitory symptoms usually continue from three to six days, terminating in those which mark the stage of invasion—viz.: slight chills, alter- nating with flushes of heat; an entire disgust for every kind of food ; tongue covered with a thin whitish fur; considerable nausea, and sometimes vomiting : a quick, small, and irregular, pulse ; a confused and heavy sensation in the head, and increased mental and physical depression. This stage generally occupies from six to twelve hours, vol. i.—12 17S TYPHUS. and terminates in the stage of excitement. The febrile heat now increases considerably, the face is slightly flushed, the pulse rises in strength and fullness, the skin becomes dry, the lips parched, there is considerable thirst for cool drinks, the tongue becomes more furred and slimy, the bowels are usually torpid, the mind is more confused, the patient fretful, restless and watchful, with an anxious expression of the countenance, the urine is small in quantity and reddish, the head feels heavy, much confused, and vertiginous; during the first two days of this stage occasional manifestations of slight delirium occur during the night. About the end of the second, or during the third day of this stage, slight catarrhal symptoms usually supervene —such as suffused and injected eyes, moderately inflamed fauces, somewhat painful deglutition, more or less oppression in the chest, attended generally with a short dry cough. There are often some ten- sion and tenderness in the hypochondria, more especially the right one. (Hildebrand.) Pains in the back, loins and extremities, are rarely absent in this stage, and in most cases a general soreness is ex- perienced throughout the whole body. Towards the close of the third day of the stage of excitement, there are usually much giddiness and sensorial obtuseness present; the patient appearing, even at this early period of the disease, as if under the influence of some narcotic. The cerebral functions now become more and more disturbed, hearing becomes obtuse, delirium more frequent and considerable, and the general torpor gradually increases. Hildebrand asserts that a pecu- culiar miliary exantheme occurs on the surface about the fourth day of this stage, which he considers as essential to the perfect and regular development of the disease. The same observation is made by Hartman.* One of the most striking characteristic phenomena of typhus is the almost insurmountable aversion to corporeal and intel- lectual exertion, manifested throughout nearly the whole course of the disease. The patient moves slowly, and, seemingly, with great reluctance, and his answers to questions are hesitating, short and peevish. The stage of excitement generally continues about six or seven days, before it terminates in the stage of collapse, though this sinking stage sometimes supervenes at a much earlier period; and occasionally comes on a few days later: The occurrence of a collapse is manifested by the subsidence of the previous inflammatory symp- toms, and the supervention of great prostration; feebleness and * In those seasons when typhus prevails most epidemically, and very remark- ably in the present (1827), it is very frequently attended by an eruption of the skin closely resembling what is seen in some of the contagious exanthemata, particularly measles. A majority of the cases treated by me in the hospitals dur- ing the present year had more or less of this eruption. It was most distinct and numerous in severe typhoid cases, but not confined to cases of any type. It was very irregular in its time of appearance and disappearance—seldom appearing, however, before the fourth or fifth day; sometimes not till the tenth or twelfth, in which last case, it was uniformly attended by an aggravation of the febrile symp- toms. Dr. Alison on the Epidemic Fever of Edinburgh; vide Edin. Med. and Surg. Journ., vol. 28, p. 244. TYPHUS. 179 greater frequency of the pulse; a dry, brown, and eventually black tongue; teeth and prolabia incrusted with black sordes; a stunned, confused and deranged state of the sensorial functions, with more or less constant, low muttering delirium ;* total apathy and indif- ference to surrounding objects; generally great difficulty of hearing; floccitacio, subsultus tendinum, twitching of the muscles of the face, great difficulty of protruding the tongue, constant recumbence on the back, and gradual sliding down towards the foot of the bed from defi- cient muscular power; a peculiar biting heat of the skin called calor mordax, and finally, in violent cases, dark spots or blotches on the slirface, a deep guttural or sepulchral voice, hiccough, and a tympa- nitic state of the abdomen. Tenderness of the abdomen to pressure, is one of the most common symptoms, in the latter periods of typhus. (Hildebrand, Broussais.) During the collapse, the urine is rather copious, pale, and often foams like beer, when voided into a vessel; there is, generally, also a manifest tendency to diarrhoea in the latter periods of this stage, the discharges being watery, acrid, and highly offensive: Towards the termination of this stage, particularly when it tends to a fatal end, coma, more or less complete, is seldom absent, from which, however, the patient may usually be roused for a few moments. The period of collapse generally continues from seven to nine days, terminating either in slow convalescence or in death. The occurrence of convalescence is announced by the appearance of a gentle and uniform moisture on the skin, a reduction of the acrid heat of the surface, a moist tongue cleaning along the edges, more copious and sedimentous urine, abatement of the delirium, and short intervals of repose, and in some instances moderate diarrhoea. In some cases these phenomena of a favourable crisis do not take place until the seventeenth or even the twenty-first day, but in the majority of instances they occur about the thirteenth or fourteenth day of the disease. The progress of convalescence is generally tedious, and the debility both of body and mind, after the total subsidence of the fever, is always very considerable. Such are the course and principal phenomena of simple typhus, in its regular progress. Deviations and various irregularities do, indeed, frequently occur, even in the simple form of the disease, but they are seldom such as to efface the peculiar character, or essential phenomena of the malady. Typhus, however, is subject to certain prominent modifications, which, as they require corresponding changes in the mode of treat- ment, require particular notice. In some instances the disease is early attended with internal visceral inflammation, a complication which adds considerably to the rapidity and danger of the malady. This modification constitutes the inflammatory typhus of Armstrong. The typhoid pneumonia, so extensively and fatally prevalent through- out this country, in the years 1811, IS 12 and 1813, was of this kind. * During the low and tranquil delirium of typhus, the mind is usually occupied and tormented by some one prominent idea or object. Hildebrand compares it to the mental workings of a somnambule. 180 TYPHUS. The brain, the lungs, the mucous membrane of the alimentary canal, the liver, and the peritoneum, are the parts most apt to be- come inflamed in typhus; and of these parts, the brain and intestinal tube are most frequently the seat of the inflammation. Most com- monly, the phlegmasial symptoms do not supervene, until the second or third day of the stage of excitement, though occasionally the local affection manifests itself much earlier. When the brain is inflamed there are generally deep and pulsating pain in the head; flushed countenance; throbbing of the carotids; redness and morbid sensibility of the eyes; irritability of temper; transient pains in the extremities ; great praecordial oppression; irre- gular respiration; continued watchfulness; visual illusions; early and almost unintermitting delirium ; a glairy and blood-shot appear- ance of the eyes; contracted pupils; intolerance of light; gloomy and agitated countenance; continued moaning and coma. (Arm- strong.) When the lungs are inflamed, the ordinary symptoms of pneu- monia are superadded to those of typhus. Pain and cramps in the inferior extremities; or, pain along the course of the spine, with irregular and difficult respiration, (unconnected with pneumonic symptoms,) and a peculiar uneasy feeling in the pit of the stomach, indicate the existence of spinal inflammation. The signs of enteric inflammation are often much more obscure. Tenderness and ten- sion of the abdomen ; an anxious and disturbed countenance ; a very small, quick, and frequent pulse ; constant recumbence on the back; much retching or vomiting ; longing for cool drink; a burning sen- sation in the pharynx; difficult deglutition and great prostration of strength, characterize this variety. The patient, however, seldom complains of pain in the abdomen, unless pretty firm pressure is made on its external surface, when his sufferings are, generally, strongly expressed, both by complaints and by the expression of his countenance. There is another modification of typhus, the congestive, which is characterized by the following phenomena : a want of febrile reaction, after the stage of oppression, the system remaining in an oppressed condition, throughout the whole or the greater portion of the course of the disease. The vital powers are overwhelmed and depressed, and the patient appears to sink, progressively, from the moment the disease commences until the vital action ceases altogether. In the more aggravated cases of this kind, there is, from the beginning, ex- treme lassitude and debility, attended with deep-seated pain in the head, with a feeling of weight and vertigo ; the face remains pale; respiration is much oppressed and slow ; the pulse is struggling, small, feeble, slow,and variable ; the skin relaxed, damp, and usually below the natural temperature ; the countenance confused, vacant, and anx- ious, the patient appearing as if stunned by a blow. The eyes are generally dull, watery, vacant, and often red ; the bowels at first tor- pid ; but in the advanced period of the disease often affected with watery diarrhoea. In the commencement, the tongue is pale, slimy, becoming rough and brown afterwards. Towards the close, pete- TYPHUS. 181 chiae, colliquative hemorrhages, and involuntary stools are apt to occur. Sometimes coma is among the first symptoms, and continues to the end of the disease ; and not unfrequently a complete state of insensi- bility and torpor supervenes soon after the disease makes its attack. (Armstrong.) Cause. —In relation to the cause of typhus, much difference of opin- ion exists among physicians. Whilst some maintain that it may be produced by any of the ordinary causes of fever,* others believe that it is essentially a specific disease, and dependent, exclusively, on a peculiar virus or morbific agent. Dr. Armstrong has advanced the opinion, that typhus is often generated by the same miasm that pro- duces remittents and intermittents; an opinion, however, which does not appear to have obtained many advocates. It is, indeed, not to be denied, that when marsh miasmata, or, perhaps, any of the usual causes of fever, act on a system which has been depressed and debili- tated by the enervating influence of cold, want of nourishment, men- tal distress, &c, a low or typhoid state of fever will be developed; but the course and characteristic phenomena of such fevers do uot accord with those which mark genuine contagious typhus. If koino- miasmata (malaria) were capable of producing typhus, we should find this disease (one might reasonably expect) among the prevailing forms of fever in all miasmatic districts, which, however, is contrary to general observation. During the years 1S22-23-24-25 and 26, miasmatic fevers were extremely common throughout nearly every section of this country ; and yet, typhus was but very rarely observed. There are, on the other hand, localities where typhus has very fre- quently prevailed with great severity, but where, intermittents and remittents are almost unknown. Dr. Smith states, that " on the Con- necticut river, from Northampton in Massachusetts to its source, a distance of more than two hundred miles north and south, and on all its tributary streams, on both sides, for a hundred miles in width, there has been no instance of any persons having contracted the intermit- ting fever, from the first settlement of the country to the present time ; and yet typhus fever has prevailed more or less in every township within that tract of country." In confirmation of his opinion on this head, Dr. Armstrong affirms that remittents often assume the appear- ance and character of typhus; and that these two forms of fever resemble each other in many of their most striking symptoms. " Re- mitting fever," he observes, " is always attended with a simultaneous affection of the brain, the mucous membrane of the respiratory pas- sages, the mucous membrane of the alimentary canal and of the liver —a combination of symptoms always present in typhus." If, how- ever, resemblances of this kind are to be admitted as evidence of identity of cause, we might, with equal propriety, refer small-pox, catarrhal fever—nay, almost every form of disease, to one and the same cause. The characteristics of typhus do not consist in any of these circumstances. With regard to the alleged conversion of re- mittents into typhus, it may be observed, that the former do, indeed, * Good's Study of medicine, vol. ii. Riel, Fieber-lehre, band. 2. 182 TYPHUS. in some instances, assume a low or typhoid character ; but this may be predicated of nearly every other variety of febrile disease, and cannot be justly urged as an argument in favour of the common ori- gin of the two former diseases. I have myself known ten cases of ordinary bilious remittents, brought together in an illy ventilated and narrow apartment, degenerate into low and putrid fevers of a highly fatal character. A system already suffering from a miasmatic disease may, no doubt, be "brought under the influence of those morbific effluvia (idio-miasmata), which are generated by a number of persons crowded into narrow, close, and sordid apartments. It can scarcely be doubted, that when these two varieties of miasmata act concomi- tantly on the system, the product will be a form of fever neither distinctly typhus, nor yet remittent nor bilious in its character.* Whatever may be the discrepancy of opinion among physicians, in relation to the existence of a typhus contagion, all seem to be agreed upon one point .-—namely, that typhus is often generated by that species of miasmata which is evolved in very crowded, confined, and filthy apartments, by the, decomposition of human effluvia. The records of medicine abound in examples of the production of typhus by the morbific effluvia generated in crowded and ill-ventilated ships, jails, hospitals, and the confined and sordid hovels of the poor. Al- though often unequivocally generated in this way, it is scarcely less certain that when once developed, typhus elaborates a peculiar virus or contagion, by which it may be afterwards communicated to those who come within the sphere of its activity. It should be observed, indeed, that there is much weighty authority extant against the exist- ence of a typhus contagion. As positive observations cannot, how- ever, be adequately countervailed by negative facts and speculative objections, we are constrained to give credence to the reality of such a contagion, by the vast body of direct testimony we have of the repeated propagation of this disease in a manner demonstrative of such an agency.t Wedekind states that, during the campaigns of the French against Russia, the typhus contagion, which was generated in the hospitals and houses crowded with prisoners and sick, was communicated to the inhabitants along the road by which the sol- diers returned; and afterwards spread gradually from the road-side to the adjacent districts, until the disease became widely prevalent. The rout of the returning army from Poland through Germany, could be distinctly traced, by the desolating train of disease it left behind. Somewhat analogous to the narcotic poisons, the miasm or conta- gion of typhus possesses a specific tendency to benumb or diminish the sensorial powers, and to depress, generally, all the vital energies. In a state of vigorous health, with the powers of vital resistance unimpaired, the deleterious operation of the typhus contagion is much * Dr. Smith on the Etiology of Epidemics, New York, 1827. t Dr. Marsh's Dublin Hospital Reports, vol. iv. In this memoir there are many cases recorded, which afford powerful evidence of the propagation of typhus by contagion. TYPHUS. 183 retarded, and often entirely prevented. In an opposite state of the system, however, when the moral and physical energies are depressed, by that combination of hardships and privations which attend suc- courless and hopeless poverty, in times of general distress, this morbific agent seldom fails, when once engendered, to manifest its deleterious powers. The typhus contagion, like that of small-pox, is capable of attach- ing itself to various substances, more especially to articles of clothing, and thus to retain its power of infecting for a long time. It is asserted, however, that clean articles of clothing are never rendered infectious by the deposition of this contagion—(Good)—an assertion which admits, I think, of some doubt. It is, indeed, sufficiently ascertained that filth of every kind greatly favours not only the development, but the activity and preservation of this poison; but we have no satis- factory grounds for denying that it may not attach itself to clothes not dirty, particularly woolens, and retain its powers of infecting for a considerable period. What length of time the typhus contagion may retain its powers of infecting, when deposited in fomites, cannot, perhaps, be definitely ascertained. Hildebrand thinks it seldom retains its activity more than about three months ;* but this, no doubt, depends greatly on various accidental circumstances—such as degrees of confinement, or ventilation, cleanliness, and the nature of the substance to which it becomes attached. Dr. Rush states, that he has known typhus pro- duced by the contagion which was left in a room six months after it had been occupied by patients ill with this disease. In a pure and free air, the typhus miasm extends but a short distance—perhaps not more than three or four feet from its source, in a sufficient degree of concentration to affect a healthy individual. It would appear that pure air is capable of dissolving or decomposing the particles of this contagion, and thus to destroy their power of in- fecting ; or, perhaps, as some maintain, the effects of free ventilation in this respect may depend chiefly, if not wholly, on the rapid dilution of the miasm in the air, and its consequent insufficient concentration to affect the system. Be this as it may, it has been well ascertained that there is but very little danger of becoming affected, in the cham- ber of a typhus patient, provided the air be freely admitted and clean- liness observed. In an impure and confined atmosphere, however, the miasm in question gradually diffuses itself throughout its whole extent, and retains a high degree of activity ; and hence, those who visit typhus patients in narrow, dirty, and close apartments are par- ticularly liable to become infected. Whatever be the virulence or activity of the typhus miasm, expe- rience has ascertained that its power of affecting the human system is greatly under the control of constitutional, as well as of accidental predisposition to its deleterious influence. It would appear, even, that the condition of the organization which constitutes this predis- position is peculiar (analogous to that which constitutes the suscepti- *Ueber den Ansteckenden Typhus, page 151. 184 TYPHUS. bility to small-pox or measles, &c.) and independent of the incidents of mere grade of constitutional vigour or health. It is asserted by Hildebrand, Hartman, and some other writers, that this susceptibility to typhus is greatly diminished by an attack of the disease; so that the liability to a second attack is, for a considerable time, at least, much lessened, if not entirely removed. Independent of this consti- tutional or natural predisposition, there are various circumstances of an incidental character, which contribute materially to enhance the deleterious influence of this miasm. I have already adverted to the tendency which impure air, want of wholesome nourishment, excess- ive muscular action, despondency, and personal filth, have in favour- ing the operation of the typhus contagion. It would appear, more- over, that the predisposition to infection, from this cause, varies with the age of the individual; for the occurrence of this disease in infancy and very advanced age is extremely uncommon. It is remarkable, says Hildebrand, that very young children, who otherwise are so very susceptible of contagious diseases, are extremely seldom affected with typhus ;* and it is almost as uncommon to meet with this dis- ease in very aged and withered individuals. No difference, in this respect, obtains in relation to sex ; but it would seem that individu- als of a delicate and relaxed habit of body are more susceptible of the typhus infection than such as are robust, muscular, and well nourished. With regard to the proximate cause of typhus, we know but little that is satisfactory. Marcus and Clutterbuck maintain, that inflam- mation of the brain constitutes the primary and essential pathological condition of this disease. They assert, that traces of cerebral inflam- mation are almost universally detected, on post-mortem inspection— an assertion which is, indeed, very often confirmed in those who die of simple or inflammatory typhus, but rarely in such as have died of the congestive form of the disease. The early, and often severe pain in the head, as well as the heaviness, confusion, and sensorial dis- turbance manifested in this disease, are adduced, also, in confirmation of this opinion. That the post-mortem evidence of cerebral inflamma- tion in typhus, is, however, far from being so general as is asserted by these writers, is manifest from the testimony of various other in- telligent observers. Dr. Kirby, director of the anatomical theatre in Dublin, observes, that the brain, supposed by some to be the seat of inflammation in typhus, rarely exhibited the characters indicative of such a state. In some this organ was much paler than usual: in a very few instances, among a great number of dissections, was there any evidence of sanguineous or serous effusion.t The same obser- vations are made by Dr. M'Cartney, professor of anatomy; and also by Dr. O'Brien.J Broussais, on the contrary, regards gastro-enteritis as the proxi- *Loc. cit, p. 169. t Transact, of the Associat. of the Fellows and Licentiates of the King and Queen's College, Dublin, vol. ii. X Ibid. TYPHUS. 185 mate or primary pathological state of this malady; and he, on his part, refers with equal confidence, to the appearances discovered on dissection, for proof of his doctrine. Hildebrand considers the proximate cause of the disease to con- sist in a condition of all the mucous membranes approaching to in- flammation, which is propagated to the sensorium commune and the nerves. It may be observed, however, that although inflammation of the mucous membrane of the alimentary canal is a very common affec- tion in this malady, and in cases of a fatal tendency, perhaps very rarely absent, it is still exceedingly improbable that it constitutes the primary and essential pathological condition of the disease, and can- not, therefore, be regarded as its proximate cause. Such inflamma- tions occur, most probably, in the course of the disease, and should be viewed as one among the ordinary morbid consequences of the fever. The importance of attending to this condition of the intesti- nal canal, in a practical point of view, is by no means lessened by the supposition of its being consecutive; for, whether primary or secondary, its reduction or removal must constitute a very essential part of the remedial treatment. Prognosis.—To the experienced physician, the general course and degree of violence of the disease, in connection with the degree and situation of the internal local inflammation, will usually afford suffi- cient data for the formation of a probable prognosis. Observation, however, has made us acquainted with various particular pheno- mena, as being indicative, either of a favourable or fatal termination of the disease, and which it is of importance to bear in mind, in form- ing a prognosis. Among the symptoms which appear to indicate a favourable tend- ency of the disease, are: spontaneous vomiting during the first and second days of the disease, more especially when the unpleasant cephalic sensations are thereby abated; slight hemorrhage from the nose, about the sixth or seventh day of the stage of excitement, is a good indication; and moderate diarrhoea, at an earlier period, is like- wise favourable. Pringle asserts, that he has often known the dis- ease subdued by the early occurrence of gentle diarrhoea ; when the abdomen remains soft, and free from pain and tenderness to external pressure, it is a favourable sign. Moderate and quenchable thirst during the stage of collapse, is said to be much more favourable, than when the patient expresses no desire to drink. A moist tongue during the collapse is a good sign; and so is a moderately free and not very frequent pulse. The most certain sign, however, of a fa- vourable termination, is derived from the state of the sensorial func- tions. If these are but slightly disturbed during the collapse, the issue will most probably be favourable. Most writers mention deafness as a good sign; Hildebrand, however, has not found this observation confirmed by his experience. The unfavourable signs are: a change in the expression of the countenance at an early period of the disease; total want of thirst; violent delirium during the stage of excitement; peripneumonic symp- 186 TYPHUS. toms. But the most ill-boding of all the bad symptoms are: blind- ness ; involuntary flow of tears; difficult deglutition ; paralysis of the tongue; continued low muttering delirium; a very frequent, small and irregular pulse ; petechia; distortion of the muscles of the face; pain, or great tenderness of the abdomen ; meteonsm; con- tinued motion of the hands, and picking at flocks ; dysenteric stools; insensibility to active vesicatories; aphtha in the mouth; involun- tary colliquative stools; colliquative hemorrhages, &c. After all, however, patients do sometimes recover from this disease after many of the most alarming of these symptoms have made their appear- ance.* Treatment.—-In prescribing for typhus fever, it is of the utmost consequence to bear in mind, that its different stages are character- ized by peculiar pathological conditions, each of which demands its corresponding modification of treatment. It is equally important, to attend to the general character of the disease, in reference to the three distinct varieties mentioned above—namely, the simple, the inflam- matory, and the congestive. A neglect of proper attention to these circumstances, has, no doubt, contributed much to the disputes which have existed, and still exist, concerning the mode of treatment best calculated to insure success in the management of the disease. There are physicians who, looking upon the employment of blood-letting in typhus as a practice always extremely hazardous, and very fre- quently ruinous, regard tonics and stimulants as the only appropriate remedies for its treatment; whilst others, equally vehement in their opposition to the use of tonics and stimulants, go to the opposite ex- treme, and carry depletion to an extent, which cannot fail, in many instances, to cause irreparable injury. The truth is, that both stimu- lants and venesection are often indispensable in the treatment of this disease; and both may prove very injurious, when employed without due discrimination, at periods and under modifications of the disease, contra-indicating their use. During the former stage of the disease, the principal indication is to overcome the torpor of the extreme vessels of the surface, and to recall the circulation from the internal to the external parts. For this purpose, an emetic is, perhaps, the most efficient and beneficial means we possess. "Vomiting excited by an emetic seldom fails to improve the condition of the skin, and to obviate the tendency to internal congestions. In many instances, indeed, the early adminis- tration of an emetic will interrupt the train of morbid actions and prevent the further development of the disease. Although especially useful in the cold stage of the disease, emetics may be used also with occasional advantage in the early period of the stage of excitement. Hildebrand, indeed, affirms that he has known decided benefit derived from the exhibition of an emetic as late as the fifth and sixth days of the stage of excitement; and the same observation is made by Pringle, StoU and Pichler.t Where there is much nausea, with a * Hildebrand, loc. cit. t Darstellungsversuch der in Mahren, 1805. Ausgebrochenen Epidemi. Bruin, 1807. TYPHUS. 187 bitter taste, and an icterode appearance of the eyes, and the arterial reaction is not violent, some benefit no doubt may sometimes accrue from the use of a vomit. As a general rule, however, the employ- ment of emetics in the stage of excitement, more especially where the febrile reaction is considerable, cannot be regarded either as useful or proper. When the disease is complicated with internal local in- flammation, they are inadmissible. To this, however, peripneumonic inflammation forms an exception ; for in this variety of complicated typhus, an emetic, after a cautious abstraction of blood, will fre- quently procure much relief. Armstrong seems to prefer antimonial emetics, but this article is apt to irritate the bowels, and to give rise to watery and exhausting alvine discharges. A large dose of ipe- cacuanha is not so liable to this objection, and experience would seem to show that, in other respects, it is quite equal to the antimony in this disease. To assist the emetic in exciting the action of the cutaneous exhalents in the chilly stage of the disease, the free use of some mild diaphoretic infusion should be enjoined, such as teas made of the eupatorium perfoliatum, balm, elder-blossom, catnip, &c. Although active purging anterior to the stage of excitement can rarely be proper, from its tendency to promote the centripetal direc- tion of excitement and the blood, yet mild laxatives ought to be among the first remedial measures. Calomel in large doses, from ten to fifteen grains, generally answers this purpose well; its usual evacuant effect being two or three copious feculent discharges, with the additional advantage of exciting the regular action of the liver. Gentle purgatives are, indeed, among our most useful remedies throughout the whole course of the disease. " The full operation of aperients in this disease," says Armstrong, " sometimes reduces the morbid heat of the skin, and the morbid force of the pulse in the stage of excitement, almost as effectually as the affusion of cold water or venesection." In the commencement of the fever, it will, in general, be proper to exhibit an active purgative, so as to procure free evacuations. Subsequently, however, it will be sufficient to procure two or three moderate stools daily, by means of suitable laxatives or enemata. Calomel followed by a small dose of castor oil, usually answers this purpose very well. Four or five grains of calomel, with a grain of ipecacuanha, may be taken late in the evening, and half an ounce of castor oil on the following morning. Even in the state of collapse, purgation sometimes becomes essen- tial to the successful issue of the case. In this, as in other low forms of fever, the brain and the whole system are sometimes greatly oppressed by intestinal irritation from acrid and offensive recremen- titious matters poured into the alimentary canal, and this is particu- larly apt to occur in the advanced periods of the disease. In such instances, the prostration is very great, the face flushed, the pulse frequent and irregular, or slow and feeble; the eyes fixed and red, with coma, delirium, or a kind of stunned torpor of the intellectual and sensorial functions. In cases of this kind, a spontaneous dis- charge from the bowels, of a dark, or black, and highly offensive 188 TYPHUS. matter, or the free operation of a purge, will frequently almost immediately improve the whole aspect of the disease. (Armstrong.) I have, in several instances, seen patients almost entirely insensible, and in a state of extreme prostration in the latter stage of typhus, speedily restored to consciousness, and a general improved state of feeling and strength, by the copious discharge of dark offensive matter from the bowels, in consequence of the exhibition of a purge. This oppressed state of the system from intestinal irritation, is especially apt to occur where proper laxatives have been neglected in the commencement of the disease, or where early spontaneous diarrhoea has been incautiously arrested by medicine. When purgatives are deemed proper during the collapse, they should be given in conjunc- tion with stimulants, particularly wine, or the carbonate of ammonia, in a mucilaginous solution. From eight to ten grains of calomel, followed by the occasional use of a tablespoonful of senna, or of a solution of Epsom salts, assisted with stimulating enemata, usually answers well in such cases. I have given castor oil with spirit of turpentine, with the happiest effect during the collapse.* We may frequently, also, obtain a free evacuation of the bowels, by the external application of croton oil to the abdomen. Four or five drops of this oil, with a teaspoonful of sweet oil, should be rubbed in on the epigastrium. I have in several instances procured copious discharges from the bowels, in the course of a few hours, by this application; and I am satisfied that it will seldom fail of producing this effect. Perhaps the most important remedy in the early period of typhus, with the view of arresting its progress, or moderating its violence, is mercury. In the simple variety of the disease, 1 have known its course effectually interrupted by a gentle mercurial treatment during the forming and early period of the stage of excitement. If the system can be brought under the mercurial influence during this period, it will often put a speedy stop to its progress. The plan recommended by Drs. Tully and Minor,! for the exhibition of mer- curials in this disease, deserves, I think, the preference. It consists in the administration of small doses of calomel, from one to two grains every three or four hours, until slight manifestations of its specific influence occur in the mouth of the patient. If this quan- tity acts too powerfully on the bowels, a few grains of Dover's powder should be added, so as to restrain, but not wholly suppress its effects in this respect. Dr. Rush states, that he has known the pulse to become full, and an evident amendment to ensue on the supervention of a gentle salivation. Dr. Warren,! of Boston, also testifies to the good effect of mercury in typhus fevers. Among the German physicians, Brandis, A. G. Hecker, Sauter, and Goeden, * R.—01. Ricini, 3i. Spir. terebinth, gii.—M. ft. To be taken in divided doses in the course of an hour. t Treatise on Fever. X The Mercurial Treatment of Fever. TYPHUS. 189 speak with decided approbation of the employment of calomel in this disease, with a view of its constitutional operation. Hildebrand, on the contrary, declares that he has never known this remedy to do any good, but often harm. With regard to the employment of venesection in typhus, much difference of opinion exists among physicians. In the simple form of the disease, it will seldom be necessary to employ the lancet; but in cases where the arterial reaction is strong in the onset of this stage, the cautious abstraction of blood will often be useful. Of late years the practice of bleeding, even in simple typhus, has been warmly re- commended by many practitioners of enlarged experience. Dr. Mills states, that of 9195 typhus patients received into the Dublin Hospital, and who were chiefly treated by blood-letting, 740 died, making the proportion of deaths nearly 1 to 11. He further states, that out of 91 patients in St. George's Dispensary, who were bled, only 1 out of 25 died ; and in another place he states, that of 504 typhus patients who were bled, he lost but 1 out of 28. Against these statements we may quote the experience of Dr. Stocker. This very respectable physician has shown from Hospital documents that the success of other practitioners who did not bleed in this disease was greater than that of Dr. Mills, they having lost but 1 out of 12 ; and Dr. Stocker, in private practice, lost only 1 out of 96. It must be confessed, that comparative estimates of this kind are liable to many objections. One thing, however, seems to be conclusively established by these statements—namely, that blood-letting in typhus, under judicious management, is by no means so dangerous a practice as was formerly, and indeed is yet by many supposed. As a general rule, blood-letting must be regarded as unnecessary, and often inju- rious in the simple variety of the disease ; but cases, even of simple typhus, do occur, in which this evacuation may be very beneficially practised. The j udicious practitioner can seldom fail to perceive when blood-letting is likely to do good. When the pulse is active, quick, and strong, or full and considerably resisting, as is sometimes the case, blood ought unquestionably to be drawn. We must, nevertheless, not forget, in the use of this remedy, that typhus is a disease attended with a radical tendency to prostration ; a consideration which will be a sufficient caution to the judicious practitioner to proceed with much circumspection in the use of the lancet, even in cases which most clearly indicate the propriety of the measure. Another very important remedy in the stage of excitement of typhus is the affusion of cold water. When employed whilst the skin is hot and dry, and the arterial excitement considerable, cold affusions often procure great relief, and sometimes give a speedy tendency to con- valescence.* A feeling of chilliness, or a temperature of the skin below the natural standard, or a moist skin, decidedly contra-indicate the use of this remedy. Under opposite circumstances, however, that is, when the skin is dry, and elevated in temperature, no remedial measure is more grateful to the feelings of the patient, or more apt to * Medical Reports, by Dr. James Currie. Dr. N. Smith, Essay on Typhus. 190 TYPHUS. mitigate his sufferings. According to Armstrong, cold affusions are rarely beneficial after the fourth day of the stage of excitement; after this period, tepid affusions, of the temperature of about 95°, he says, ought to be used. In general this may be correct, but where the sur- face is dry, and above the ordinary degree of heat, we may safely and beneficially use affusions at a considerably lower temperature. When the heat of the surface is unequally distributed, partial ablu- tions of the hands or feet will sometimes have a favourable effect. The existence of visceral inflammation forms an objection to the use of this remedy. After the heat of the skin has been reduced by the affusion of cold water, the patient should be dried and laid between two blankets, and warm diaphoretic tisans administered—such as catnip, balm, or sage tea. When the brain is much affected, we should place the feet in warm water while the cold water is upon the head and over the body. (Armstrong.) Diaphoretic remedies, such as the spiritus mindereri, the saline ef- fervescing draught, spirit, nit. dulc. with vin. antimonii and laudanum, may be employed as auxiliaries to the more efficient means already indicated in the stage of excitement.* Active sudorifics, however, are rarely admissible. A cup of the elder blossom tea, with twenty or thirty drops of the sweet spirits of nitre, may be given every two or three hours during the stage of arterial reaction. In cases attended with considerable bronchial irritation and cough, Goeden recommends the use of muriate of ammonia in solution, with a large portion of mucilage, and the extract of liquorice to disguise its disagreeable taste.t When the stage of collapse has supervened, the plamof treatment must be exciting and roborant. In the employment of stimulants, however, much caution and circumspection must be used, lest latent inflammations be roused by over-stimulation. In some instances, the tendency to visceral inflammation is kept down by the antiphlogistic measures used in the preceding stage ; but no sooner are stimulants given on the occurrence of collapse, than violent delirium ensues, the eyes becoming red and filmy, the face flushed, in short, unequi- vocal symptons of cerebral inflammation coming on. (Armstrong.) Should the delirium, therefore, become more violent, the skin dry and very hot, and the pulse more frequent and corded, on the ex- hibition of stimulants, we must either omit their further use, or employ only the milder articles of this kind. When the sensorial dis- * R.—Spir. mindereri ^vij.—Liquor Ammonia? Acetati. Vin. antimon. giss. Spirit, nitr. dulc.gij. Tinct. opii, gtt. 45. Syrup limonis jfij.—M. Dose, a tablespoonful every two hours. t R.—Muriat. Ammon. Sjiss. P. g. Arab. sij. Extract. Glycyrrh. giij. Spirit. Nit. Dulc. giss. Acid. Scillaj 3iii.—M. Dose, a tablespoonful every two hours. TYPHUS. 191 turbances are moderated, or not increased, and the pulse becomes slower, and somewhat softer and fuller, and the skin less acrid and hot, on the exhibition of stimulants, we may proceed with confidence in their employment. It is best always to begin with the weaker stimulants when the period for their use has arrived. Flildebrand speaks in very favourable terms of the rad. contrayerva, and par- ticularly of the angelica. When the collapse is not great, these and other analogous articles may often suffice, but in instances of great prostration and sinking we must resort to much more potent excit- ants. Wine is an excellent stimulant in the collapse of fevers. The white wines are the best, and of these Madeira is perhaps the prefera- ble one. The carbonate of ammonia also is much employed in this country in the low states of fever. From its diaphoretic tendency, it may in general be administered much earlier on the supervention of collapse than wine, for instead of increasing the heat and dryness of the skin, an effect not unfrequently the consequence of the adminis- tration of wine, it generally causes a softness of the surface, and a freer and less irritated action of the heart and arteries. It must be given in solution, mixed with a large portion of mucilag. Thus: R.—Carbonatis amnion, 3ij. Pulv. g. arab. §iij. Sacch. albi, §ss. Aq. fontanae §yiij. Tinct. opii, gtt. 40.—M. ft. S. A tablespoonful every hour or two. In extreme cases, wine and the carbonate of ammonia may be given conjointly with advantage. Indeed, when we consider that ammonia has a tendency to counteract the inebriating effects of alco- holic liquors, we have reason to suppose that the union of these two articles is peculiarly apropriate as a stimulant in this disease.* Cam- phor has been long celebrated as a stimulant in cases of low fever w ith much functional disorder of the brain. The Germans, especially, place great reliance on its use, in instances of this kind. Hildebrand asserts, that in the collapse of typhus, it is one of our most valuable remedies. Its power of moderating sensorial disturbances—particu- larly delirium, is often more decisively manifested in this disease than that of any other remedy we possess. I have myself had repeated evidence of its virtues in this respect, and am inclined to think that it is not sufficiently estimated by the profession in this country. Camphor may be very conveniently given in the form of solution in sulphuric ether. Thirty or forty drops of a solution of two drachms of camphor to an ounce of ether,'may be given every hour or two. Perhaps the best way, however, of administering this article, is in the form of a mixture—thus: R.—Pulv. camphorae, 3ij. ----G. arab. 3iij. Aq. fontanae, 3viij. Liq. anod. Hoff. 3ij.—M. ft. S. A tablespoonful every two or three hours. [* The late Dr. Kuhn is reported to have said, that he had seen more lives saved under desperate circumstances by Carb. Ammonia and wine whey, than by all other remedies whatsoever.—Mc] 192 TYPHUS. Musk, also, has been much praised as a stimulant in the collapse of typhus. Where symptoms of nervous excitement are conspicu- ous, such as subsultus tendinum, tremors, hiccough, delirium, with a copious, pale urine, it will no doubt often do considerable good. In this country, however, we seldom get the genuine article, and as good musk is very expensive, and not upon the whole more efficient than the articles already mentioned, it is not often used by American practitioners. Opium was formerly a good deal employed in the advanced stage of this disease. Sydenham speaks favourably of its powers, and Cullen thought it valuable for allaying the low delirium in the col- lapse of the disease. In that oppressed state of the system which is sometimes caused by intestinal irritation in the latter period of typhus and typhoid diseases—and which is characterized by much jactita- tion, flushed face, stupor, or partial coma, with a very small flutter- ing pulse, I have known opium to procure great relief, especially after the operation of a purgative. In general, however, opium is of very doubtful efficacy in this disease—more especially where there is reason to apprehend much cerebral congestion or an approach to inflammation. In all instances, however, where great prostration is attended with much general nervous irritability and sympathetic cerebral disturbance, opium is a valuable remedy; but where the sensorial and nervous energies are torpid, as they almost always are in genuine typhus, its effects must be, generally, mischievous. When profuse and exhausting diarrhoea occurs, or dysenteric symp- toms, opium with minute portions of calomel will often do much service. In such cases, I have used small doses of Dover's powders; three grains every two hours, with decided benefit. Phosphorus is a most potent stimulus; but its tendency to excite mucous inflammation renders it a hazardous remedy in a disease which is so prone to gastro-enteritic inflammation. It is but seldom used. The flowers of the arnica montana is a favourite remedy in this disease with the German physicians. Collin, (Annus Med. Coutin), StoU and Hildebrand, declare that they have used it with marked benefit in the collapse of typhus. It is said to moderate the sensorial torpor and delirium of the disease more certainly and safely than any other remedy we possess. It is given in infusion, in the pro- portion of one ounce to a pint of water, of which a tablespoonful is exhibited every hour. Goeden asserts that the arnica has a specific tendency to act upon the brain. Tonics do not possess much power in counteracting the prostration in the collapse of this disease. Their operation is much too slow to afford sufficient support where the vital powers are so rapidly sink- ing. In this observation we ought, perhaps, to except the sulphate of quinine; for it can scarcely be doubted that the liberal use of this potent tonic would frequently contribute promptly, and very efficiently, to the support of the vital energies. Given in doses of from four to six grains every hour or two, it could scarcely fail of TYPHUS. 193 elevating and sustaining the actions of the system, where sufficient excitability remained to the impression of such remedies. Blisters are very variously estimated as remedial t agents in typhus. Applied about the period when the stage of collapse is approaching, that is, about the seventh or eighth day of the fever, they sometimes exert a very beneficial influence on the disease. At an earlier period they are apt to increase the general irritation of the system; and at a more advanced stage, vesication tends to in- crease the exhaustion, and there is much danger from gangrene of the blistered surface. When applied at the proper time, blisters will often improve the state of the skin, and tend to remove irregular determinations of the blood. Applied to the back of the neck, they generally moderate the cerebral disturbance, more especially where meningeal inflammation is present. It is not necessary, nor in general proper, to suffer the vesicatory to remain on the skin until vesication is produced. When the skin is red, which will generally occur in the course of five or six hours, the plaster should be removed, and an emollient poultice applied in its stead. This will rarely fail to raise a blister in a few hours. During the collapse, or while the patient is delirious, frequent attention should be paid to the state of the bladder. Not unfre- quently the urine is retained until the bladder is greatly distended— an occurrence which cannot fail to add to the distress of the patient, and aggravate the general nervous and vascular irritation. When there is reason to suspect the existence of this condition of the bladder, immediate recourse ought to be had to the catheter.* What has been hitherto said, applies especially to the simple form of the disease ; and it remains for me to speak of the modifications of treatment proper, when visceral inflammation, or violent internal congestions, attend the malady. In cases of inflammatory typhus, the antiphlogistic remedies must be promptly and efficiently urged. Blood-letting is here our main stay ; but in order that it may prove beneficial it must be employed soon after the supervention of the inflammation. " If it be delayed to the second or third day of the inflammation, it can no longer be employed without risk of irreparable injury." As a general rule, bleeding is seldom proper after the first twenty-four hours from the commencement of the inflammation: for the stage of collapse is apt to supervene rapidly on the occurrence of inflammation in this disease. (Armstrong.) It is always best to take away as much blood at once as will make a decided impression on the system. Dr. Armstrong advises that the blood should be suffered to flow until an approach of syncope is induced, and to effect this with as little expenditure of the blood as possible, the patient should be supported * [During the malignant typhus which prevailed in the Philadelphia Alms House, in 1817—18, a.post-mortem examination revealed an over-distended bladder, in every fatal case, until the catheter was resorted to as a palliative remedy. In several cases this resort gave immediate relief to the coma and delirium, and enabled stimuli and nutriment to restore the strength.—Mc] VOL. I.---13 194 TYPHUS. in an erect or sitting position, while the blood is flowing. It is not necessary, generally, to take away much blood in typhus to produce an adequate effect. Unless a decisive impression be made on the system, however, little or no benefit will result from this measure. Topical bleeding by leeches or cupping, especially when the inflam- mation is seated in the abdomen, is also an important means for subduing the phlogistic character of the disease. Too much danger is apprehended, by many physicians, from blood-letting in inflam- matory typhus. It cannot, indeed, be pretended that the use of the lancet is without risk in an unskilful hand; but it may be confidently maintained, that in cases attended with visceral inflammation, blood may be abstracted both by venesection and leeches, not only without mischief, but with the greatest advantage, provided it be early prac- tised, and under the guidance of a judicious estimate of the powers of the system, and the exigencies of the case. When the inflam- mation, is seated in the brain, much good is often to be obtained from,the application of cold water or ice to the head. In instances complicated with pulmonic inflammation, calomel and opium, after blood-letting has been performed, is a remedy of excellent powers. A grain of each may be given every three or four hours. In the typhus pneumonia, which was so prevalent in this country in 1812, I employed this remedy in a number of cases, and frequently with marked advantage. Indeed, when we advert to the fact, that these two articles, in combination, have been highly extolled by many very eminent writers,* in inflammation of the lungs, attended with a high grade of vascular action, we can scarcely doubt of their appli- cability in pneumonia, when .connected with fever of a low grade of excitement. The pain and distress caused by the inflammation, generally soon abate considerably under the influence of this remedy; the skin often becomes moist and cooler, and the pulse more expanded, and less frequent. It must be recollected, however, that where there are symptoms indicative of cerebral inflammation, opium is wholly out of the question. It is particularly in pneumonic inflammation that the combination of calomel and opium is valuable; and much benefit may also be sometimes obtained from it in abdominal in- flammations. In leaving this subject, it may be proper to remark, that typhus fever, whether simple or inflammatory, is always attended with a radical tendency to prostration. The pulse may at first be full and active, yet the vital powers are essentially, and ab initio, debilitated by the influence of the remote cause of the disease. This declara- tion does not contradict the recommendation of antiphlogistic means in the stage of excitement. Radical debility and inflammatory action are by no means incompatible: nor need we apprehend danger from a judicious employment of antiphlogistics, where much general vascular irritation is associated with debility of the vital energies. Neverthe- less, the practitioner should not forget, that whilst he is employing such measures, there is lurking at the bottom a tendency to ultimate Armstrong, Hamilton, Schmidtman. TYPHUS. 195 prostration and exhaustion. With this precautionary view of the general character of the disease, he will always proceed with due care in the use of depletory measures, and keep a watchful look out lest the patient be incautiously precipitated into a fatal state of ex- haustion. In the congestive modification of typhus, Dr. Armstrong recom- mends blood-letting as the most efficient means for relieving the heart and internal organs from the overwhelming load of blood, and re- exciting the oppressed action of the heart and arteries. As the internal congestions, however, appear to be the consequence of a previous loss of energy in the vital powers, and especially of the extreme vessels, it would seem most efficient and prudent to endea- vour to remove this condition by means calculated to impart warmth and vigour to the system, and to recall the circulation to the extreme vessels of the surface. The means best calculated to effect these salu- tary changes, are stimulating frictions and warm applications to the external surface. Bottles filled with hot water, applied to different parts of the body, and frictions with tincture of capsicum, or flannels wrung out of hot brandy, are among the most effectual means for exciting the action of the extreme vessels, and deriving the circula- tion from the internal organs. Measures of this kind possess the pe- culiar advantage, in the congestive forms of fever, of exciting the energies of the system instead of diminishing its resources, at the same time that they most efficiently tend to equalize the circulation and remove the congestion. It should be recollected, that typhus is a dis- ease of debility—that the powers of life are weakened from its com- mencement—and that, consequently, that mode of treatment is best which answers the purpose in view with the least expenditure of the resources of the system. Most assuredly, therefore, the removal of internal congestions by a gradual and invigorating excitement com- municated to the nerves and capillaries of the surface of the body, must be much more safe than the attempt to accomplish the same purpose by abstracting blood from the patient, which, though per- haps adequate to remove the congestion, may readily convert appa- rent into real weakness. That the external and internal exciting measures just mentioned are, in truth, more efficient for removing the congestive states of fever than direct depletion, may beinferred from the observations of Dr. Armstrong himself. " When, after bleeding," he says, "the pulse still remains oppressed, and the tide of circulation does not return to the surface, some wine with warm water should be occasionally exhibited, and the patient speedily immersed in a bath strongly impregnated with salt, and about the temperature of 100° of Fahrenheit. On leaving the bath, the patient should be" well rubbed all over with hot flannels, and then laid in an aired bed with bottles of warm water applied to his feet. This plan will often promote the flow of blood to the surface." Now, if even in the most aggravated cases of congestive fever, the internal exhibition of wine, with warm and stimulating applications to the surface, will determine the blood to the extreme vessels, and remove the oppressive internal congestion, we may conclude a fortiori, that in the milder ^stances of the con- 196 TYPHUS. gestive state, this exciting plan of treatment will be still more apt to recall the blood to the surface and equalize the circulation. In addition to the above means for overcoming oppression from internal congestions, blisters, large doses of calomel, and purgatives, are important remedies. The bowels should be freely evacuated as soon as the reaction of the heart and arteries is in some degree re- established. Calomel in large doses appears to be peculiarly adapted to cases of this kind. From ten to twenty grains must be given every three or four hours until the bowels are moved, and its operation pro- moted by stimulating enemata. Dr. Armstrong observes, that " the power of equalizing the circulation is nowhere more conspicuously displayed than in diseases of a congestive character. Before the exhibition of it the skin will be warm and shrunk, the pulse feeble and oppressed, and the whole system apparently relaxed; but no sooner is the mouth made sore by its specific influence, than the skin becomes warm, reddish, and distended with the invigorated circula- tion, while the pulse is full, soft and strong, and the general energy in a great measure restored." My own experience accords fully with these observations. At the same time that calomel is given with the twofold object of procuring its purgative and constitutional influence, active, rubefacients or sinapisms may be, advantageously applied to the epigastrium. (Armstrong.) The congestive form of typhus often terminates fatally in a few days, and is always rapid in its course. Our remedies must, therefore, be promptly and diligently applied in cases of this kind. After the reaction has been established, the same general plan of treatment applicable to simple typhus must be pur- sued. With regard to the dietetic management of this disease, it is scarcely necessary to state that the simplest kinds of liquid nourishment are alone admissible. Of these, however, the patient may be allowed as much as he can be induced to take, more especially during the sink- ing stage of the complaint. By keeping the stomach and bowels moderately distended with bland liquids, considerable support is given to the sinking powers of the system, and good, moreover, probably arises from it by its tendency to allay intestinal irritation, and afford- ing the absorbents a supply of mild and invigorating fluid for the support of the system. Dr. Stoker states, that in the late epidemic typhus of Ireland, many of the patients who were brought into the Dublin Hospital, began to recover almost immediately on being allowed the free enjoyment of mild nutritious fluids. Dr. Samuel Colhoun, of this city, adopted a similar plan of treatment in the Pennsylvania Hospital, some years ago, and the result was entirely favourable.* During convalescence, tonics in moderate doses, such as the infu- sions of cinchona, serpentaria, chamomile, slightly acidulated with sul- phuric or nitric acid, may in general be employed with advantage. The diet during this period should be mild, digestible, and nourishing, and particular care must be~ taken not to oppress the stomach by * See his essay on this subject, in the fourth volume of the Medical Recorder. TYPHUS. 197 taking more food at a time than can be easily digested. Weak wine and water may be taken occasionally.* * [Of late very respectable attempts have been made to separate the cases of continued fevers which occur in Europe and this country into two distinct species or forms;—one of which is called typhus, and the other typhoid or ileo-typhus. Among those who have written most elaborately and classically upon this subject is Professor Bartlett, now of the Maryland University. Dr. Gerhard, of this city, has also published many excellent observations in elucidation of this subject and in confirmation of the views of Louis. The typhus prevails in London, the ty- phoid in Paris. The latter is, according to. Dr. Gerhard, the most common form of continued fever in this country. In typhus there is more congestion in the brain and substance of the lungs—hence it has been donominated by some bron- cho-typhus. In this form there is more stupor, which begins earlier and is present in every case. Delirium and subsultus are almost invariably present. The skin, if there be any power of reaction, is always hot and burning. The pulse, rapid and variable: often undulating. The tongue dry and black, the fetor intolerable. In typhoid fever there are less stupor, delirium and subsultus—indeed, these symp- toms are often absent. The tongue is less darkly furred than in typhus—this con- sisting generally.of a white fur until the later stage. The pulse is less frequent and more steady. The skin less hot—often moist and perspiring throughout the whole progress of the disease. The eruptions in typhoid fever are confined mainly to the abdomen, and do not extend over the whole surface as in typhus. In fact, typhus has been regarded as a really exanthematous disease in conse- quence of a universal eruption of petechias, which generally appears about the fourth day, and but partially disappears on pressure. The average duration of typhus is less, and death often takes place earlier than in typhoid fever. The most striking of the post-mortem appearances in typhus is that of congestion or engorgement in the lungs, and also in the brain. The blood is dark-coloured, and often fluid or dissolved. But there is no real anatomical character in typhus, such as prevails, according to Louis, in all cases of typhoid fever. There are well-marked lesions of the alimentary canal and of the spleen. The spleen enlarges and softens remarkably, but gradually recovers its natural condition in case the patient gets well. The true anatomical character of this dis- ease, however, is an inflammation, enlargement, and finally ulceration of the con- glomerate glands of Peyer, above the termination of the small intestines, near the ileo-colic valve. The follicles of Bruner are sometimes also affected, and the same appearance extends down some distance into the colon. The mesenteric ganglia are also often inflamed and softened in connection with the intestinal fol- licles with which they are associated by the lacteals. If the patient recovers, the ulcers gradually cicatrize, and the enlargement of the mesenteric glands disap- pears. In the meanwhile, however, the patient is subject to a diarrhoea and tym- panitic distension, and occasionally to bloody evacuations. The English physicians do not, as yet, appear to have given in their adhesion to the doctrine of Louis, but generally regard these organic lesions as accidental complications—not essential to the character of any disease. In this country, however, a large portion of the profession consider them as peculiar and essential— bearing the same relation to typhoid fever as the pustules of small-pox maintain with the febrile symptoms of that contagion.—Mc] 198 INFLAMMATION IN GENERAL. II.-GENERAL IRRITATIVE DISEASES OF THE BLOOD-VESSELS, CON- NECTED WITH, OR DEPENDENT ON, LOCAL INFLAMMATION. CHAPTER IX. OF INFLAMMATION IN GENERAL. Preliminary to considering the general affections which properly belong to this head, it will be necessary to treat of the phenomena, nature, and progress of inflammation. The scope of this work does not admit of a full discussion of this interesting subject, but it is be- lieved that the following summary will be found to embrace all that is really important or well established in relation to this form of vas- cular disease. Although inflammation is characterized by pain, increased heat, redness and swelling, yet none of these phenomena are to be regarded as strictly essential to its existence. Each of these phenomena, too, is greatly diversified in its character, according to the nature of the structure in which the inflammation is located. Thus pain, though generally present, is not always so, and it would seem that the looser the structure, the less violent in general will be the sensation of pain. Inflammation of the lungs, of the mucous membrane of the stomach and bowels, of the brain,* and of the pericardium, has been found from the commencement, to its termination in death, entirely unat- tended with pain. Even the character of the pain is modified by the nature of the inflamed structure. In the mucous membranes it is burning or stinging ; in the pleura it is lancinating and generally extremely acute; in the ligaments, or fibrous structures, it is dull, aching, and gnawing; and in the nerves rapid, darting, and excruciat- ingly severe. But although the pain may sometimes be very trifling or even absent in inflammation, a feeling of soreness or aggravation on pressure always occurs. In this, inflammatory pain differs essen- tially from the pain which attends spasm. The violence of the sympathetic febrile reaction is in general pro- portionate to the intensity of the pain experienced in an inflamed part. Thus, in acute bronchitis, or peripneumonia notha, there is neither very severe pain nor very vigorous reaction of the heart and arteries; whereas, in inflammation of the pleura, both the pain and the febrile reaction are almost always extremely great. Increased heal is another general phenomenon of inflammation which is sometimes absent. The sensation of heat in an inflamed * Med. Chir. Rev., Jan. 1827, p. 234. INFLAMMATION IN GENERAL. 199 part does not appear to depend on any actual accumulation or ele- vation of temperature measurable by the thermometer, but on the altered state of the sensibility of the nerves implicated in the inflam- mation ; for the sensible heat of an inflamed part rarely indicates more than 90° of Fahrenheit's thermometer.* The most invariable phenomenon of inflammation is redness. It arises from the passage of red blood into the serous capillaries, which either from debility, and consequent relaxation, or from an altered state of their specific sensibility, offer no resistance to the intromis- sion of the red globules of the blood. This redness generally remains after death, and affords one of the ordinary post-mortem evidences of inflammation. Redness, by itself, however, cannot be regarded as a certain sign of previous inflammation, for the serous capillaries may become injected with red blood in articulo mortis, although wholly free from previous disorder. I have already adverted to this fact, and to the erroneous inferences it may lead to, in the preliminary chapter on the pathology of fever. Swelling is always more or less present in the soft structures, and appears to depend on effusion of serum into the surrounding cellular tissue, and on the dilatation of the capillary vessels. The firmer the structure is, the less swelling will occur from inflammation. Inflammation is an affection of the capillary system of vessels, and appears to consist of an altered condition of their vital properties, with inordinate sanguineous congestion, and hence the more abun- dant the capillaries of a part are, the more apt it is to become in- flamed. The mucous, serous, cellular and dermoid structures being peculiarly vascular, are much more frequently affected with inflam- mation than the osseous, cartilaginous and tendinous structures.— (Bichat.) Inflammation may be produced, 1. By the direct operation of irri- tating causes on the animal structure; as wounds, bruises, burns, mustard, cantharides, turpentine, the acids, or various caustic sub- stances. 2. By the indirect operation of irritants, through the me- dium of the nervous system. Thus, acid in the stomach will some- times give rise to superficial cuticular inflammation ; and meningeal inflammation is frequently the consequence of irritants acting on the mucous membrane of the intestinal canal. 3. By general increased action of the heart and arteries, as frequently occurs in synochal fever, where any portion of the capillary system is accidentally debi- litated, and thereby predisposed to inflammation. It is in this way that most of the inflammations which occur in fevers arise, for when the momentum of the general circulation is augmented by the in- creased action of the heart and arteries, the blood will, by its impe- tus, be forced into those capillaries which, from debility, either acci- dental or induced by the remote febrific cause, offer less resistance to its intromission than they do in a state of natural vigour. 4. By metastasis; thus, erysipelas sometimes passes in and fixes upon an internal organ ; and gout occasionally passes from the feet to the sto- mach, brain, and to various other parts. * Hunter on the Blood. 200 INFLAMMATION IN GENERAL. Whatever may be the remote existing cause of inflammation, it is probable that the following changes are effected in the progress of its evolution. 1. Irritation, that is, a certain inordinate or hurtful impression on the nervous filaments of the part, by which a new and irregular excitement is produced in them, called irritation. 2. Alter- ation of the vital properties of the capillaries of the part thus irri- tated or disturbed by the unnatural impression; and 3. An afflux, or determination of the blood to these capillaries. (Bichat.) These changes often succeed each other so rapidly, that they seem to occur simultaneously. A change in the sensibility and irritability of the capillaries, would seem to be essential to the existence of inflamma- tion; for where these vital properties remain in their normal state, preternatural determination of the blood into them does not constitute inflammation, but only congestion, or local plethora.* Are the capillaries of an inflamed part in a state of debility and passive relaxation, and is the velocity of the blood circulating in them diminished, as is contended by Vacca, Lubbeck, Allan, Philip, and Hastings; or, are these vessels in a state of increased action, and the momentum of the blood within them augmented, as is main- tained by Hunter ? Upon these points, there has been a great deal written both pro and con, and the subject is still not well settled. My own view on this subject is, that the inflamed capillaries ought to be regarded as being in a state of irritation, and that this irritation may -be connected either with an increased or decreased power of action. In this respect, local inflammation corresponds with that general irritated vascular excitement which constitutes fever. The heart and arteries are in a state of irritation, with increased power of acting in synocha. In typhus, there is also general vascular irrita- tion ; but it is connected with a fundamental debility of the vital powers. There is, therefore, according to my apprehension, a typhus and a synochal state of local inflammation; and this corresponds with the results we obtain from remedial applications. May we not explain these different diatheses of inflammation by the greater or less degree of organic injury sustained by the nervous filaments of the inflamed capillaries ? When a part is irritated, so as to exalt the sensibility of the capillaries, by exciting their nervous texture, the consequent inflammation will probably be one of increased capillary action, and demand sedatives for its cure ; when, on the contrary, the irritating cause acts with such violence as to cause structural lesion in the nervous extremities, or when from the long continuance of the inflammation, the capillaries have in some degree lost their energies, the inflammation resulting from its action will be character- ized by debility, and demand stimulating applications, as is the case in scalds and burns. Terminations of inflammation.—Inflammation is said to termi- nate in resolution, when it declines, and disappears without having induced any structural lesion, or perceptible discharge. It consists in a gradual return of the vital properties of the inflamed part to Bichat. General Anatomy. INFLAMMATION IN GENERAL. 201 their natural condition, and a consequent resumption by the capil- laries of their ordinary or healthy action, before either some portion of the affected parts is destroyed from total loss of vitality, or new secretions are formed by the morbid action of these vessels. Termi- nation by resolution is always more prompt in proportion as the inflamed part is endowed with a higher degree of vitality. (Bichat.) Frequently the termination of inflammation by resolution is accom- panied by an increase of the natural secretions of the affected organ ; and this is particularly noticed in the mucous membranes, as in catarrh and coryza, where an increased secretion of mucus always announces the favourable termination of the inflammation. The same fact is also conspicuously exemplified in rheumatic inflamma- tion, which rarely terminates without an increased exhalation of serum into the surrounding cellular structure. Effusion is another * of the terminations of inflammation. The fluid effused may be either blood, or lymph, or serum. The termination by effusion of blood occurs most commonly from the softer and more vascular structures, more especially from the surface of mucous membranes. Lymph and serum are rarely effused from this structure, these effu- sions being almost peculiar to the serous membranes. The lymph which is thus effused in the declension of inflammation from serous membranes, often forms a bond of union, and causes firm adhesion between them when contiguous to each other. It is thus that the costal afld pulmonic portions of the pleura are so frequently found united, in consequence of thoracic inflammation. In the mucous membranes, such adhesions never occur from inflammation; and ,this is one of those wonderful adaptations in the animal economy, in which the benevolent design of an all-wise Providence is especially conspicuous; for without this peculiarity in the mucous structures, we should be continually liable to the adhesions between the sur- faces of the various excretory ducts, as well as of those of the aliment- ary canal and respiratory passages, since these are more frequently affected with inflammation than any other parts of the animal system. When lymph is effused into the substance of the solid viscera, or into the cavities of the cellular tissue, it causes a consolidation of these parts, forming what are technically called indurations. The spleen, liver, and lymphatic glands, are particularly liable to these conse- quences from inflammation. Suppuration, also, is one of the modes in which inflammation is wont to terminate. Of all the animal tissues, the mucous and cel- lular are most liable to this mode of termination. The bones and tendons never enter into the suppurative action from inflammation ; and the serous membranes, though liable to suppuration from in- flammation, are much more apt to pour out an increased flow of ' serous fluid. The product of the suppurative process differs con- spicuously in the different structures that are liable to it. In the mucous membranes, the fluid elaborated by this morbid action con- sists of a whitish, cream-like, or greenish appearance, denominated pus. In the serous membrane, the pus is formed by a kind of ex- halation, and consists of a thin, whey-like fluid, generally intermixed 202 INFLAMMATION IN GENERAL. with flakes of coagulated lymph. Suppuration of the cellular tissue produces a thick pus, of a pale-yellow colour and uniform consistence, exhibiting, under the microscope, the appearance of minute globules suspended in a serous fluid. The grade of inflammation which results in suppuration, transcends that which is necessary for the se- cretion of lymph; and hence, round the circumference of inflamed parts, involving cellular tissue, where the inflammation is less active than at the central portions, lymph, and not pus, is formed: in con- sequence of which, the cells adhere to each other around the internal suppurating space, and form a circumscribed cyst or cavity in which the pus is retained, constituting an abscess. The occurrence of sup- puration in an internal organ, is generally manifested by a sensation of weight in the region of the affected part; a change from an acute to a heavy, dull, and throbbing pain; rigors; a change from a hard, tense, and quick pulse, to a soft and moderately full one; night sweats, and other symptoms of hectic. Inflammation may also terminate in gangrene. This mode of termination never occurs in the cartilages, nerves, and bones: the mucous, cellular, and serous tissues being most prone to it. Of the serous tissues, the peritoneum appears to be most apt to becbme gangrenous from inflammation; and of the mucous membranes, that which lines the alimentary canal is most subject to this termination. The occurrence of gangrene is attended with a sudden cessation of pain; sinking of the pulse ; cold extremities ; cold sweat; indistinct- ness of vision; slight delirium; and a cadaverous expression of the countenance. The four modes in which inflammation terminates, appear to be determined by four corresponding grades of the inflammation. This is strikingly illustrated in the phenomena of common phlegmon or boil. Along the circumference, where the inflammation is weakest, there is serum effused into the surrounding cellular structure; a little further towards the centre, where the inflammation is somewhat greater, lymph is thrown out, and adhesions formed; within this circle, where the inflammation is still more violent, pus is secreted; and at the central portions gangrene and sloughing occur. (Hunter.) The different forms of inflammation manifest different tendencies in relation to these terminations. In boil and whitlow, there is an especial tendency to suppuration; in carbuncle, the disposition is to terminate in gangrene; and in rheumatism and mumps the tendency is strongly to resolution. Indeed, so strong are " these original dis- positions to terminate in one mode rather than another, that it is very difficult to procure any other termination than the one to which the tendency exists."* Inflammation occurs under five prominent modifications, corre- sponding to the five elementary tissues, viz.: the cellular, the serous, the mucous, the dermoid and the fibrous. 1. Inflammation of the cellular tissue or phlegmonous inflamma- * Observations on the Nature and Treatment of Inflammation. By J H James, p. 17. INFLAMMATION IN GENERAL. 203 tion is characterized by great swelling, throbbing pain, and by its peculiar mode of suppurating—the pus being collected in circum- scribed cavities. 2. Inflammation of the serous structures, or serous inflammation, distinguished by very acute lancinating* pain; little or no tume- faction ; much sympathetic reaction of the sanguiferous system; by its tendency to terminate in the exudation of coagulable lymph or serum, or the secretion of a thin, whey-like pus. It is peculiarly rapid in its course, and is not apt to terminate in gangrene. Ad- hesions are peculiar to this and the former modification of inflam- mation. 3. Inflammation of the mucous tissues or mucous inflammation, is attended with a burning or stinging pain, without tumefaction of the subjacent, cellular structure; the sympathetic fever attending it is not vehement; and it never terminates in resolution, without an increase of the mucous secretion. 4. Inflammation of the dermoid system, or erysipelatous inflam- mation, is attended with a burning pain; it spreads irregularly over the surface of the skin, forming vesicles or blisters, containing a transparent straw-coloured serum, and never forms adhesions, or suppurates in circumscribed cavities. This variety of inflammation generally depends on constitutional causes, and it would seem, in some instances, on a specific cause. 5. Inflammation of the fibrous structure, or rheumatic inflamma- tion, is accompanied with intense aching or gnawing pain; and is particularly indisposed to terminate in suppuration or gangrene—its almost universal termination being in the exudation of serum and a gelatinous fluid, or in the deposition of earthy matter. It is apt to change its situation from one place to another, and sometimes passes suddenly to the internal organs. The sympathetic fever which ac- companies its acute form is always very vigorous. This modifica- tion of inflammation rarely proves fatal, unless "by metastasis to organs essential to life. The existence of internal inflammation is ascertained by the pain continuing without much remission; the appearances of the blood, which, when drawn, very generally exhibits a sizy or buffy crust on the crassamentum ; by the presence of faver, which does not attend spasmodic or nervous pain, by the effects of external pressure, more especially in abdominal inflammation —thus causing an aggravation of the pain, or a feeling of great soreness—whilst in spasmodic pain, a mitigation of the patient's sufferings is usually the consequence of pressure. The effects of position also throw light on the diagnosis of internal inflammation ; thus, in abdominal inflammation, the patient lies on his back, with the knees drawn up, and the head and shoulders raised, in order to obviate pressure from the tension of the abdominal muscles. The character of the functional derangement, moreover, will assist us in ascertaining the existence of internal visceral inflam- * [This is true of the pleura. In the peritoneum, however, there is generally an exquisite tenderness.—Ma] 204 GLOSSITIS. mation; and, finally, the nature of the exciting causes will aid us in the diagnosis. Inflammation occurs under two principal varieties, in relation to the rapidity of its progress and the violence of its phenomena— namely, acute and chronic inflammation. The former is rapid in its course, and violent both in its local and symptomatic phenomena. The latter is generally, though not always, the consequence of the former, and is characterized by a slow progress, and much less intens- ity in all its symptoms. In the serous membranes, chronic inflam- mation results either in the effusion of serum, giving rise to dropsical accumulations, or to a gradual change of structure, such as thicken- ing and induration, and frequently to the formation of miliary tuber- culous matter. In the mucous tissues, the usual consequences of this variety of inflammation are phthisis, diarrhoea, dyspejisia, and various other local and general affections; and in the solid viscera and glandular structures, induration, scirrhus, and other organic changes are its effects. To the pathologist and medical practitioner, the sympathetic phe- nomena of inflammation constitute one of the most interesting and important objects of attention. Among the multifarious febrile affec- tions that are met with in practice, whether acute or chronic, there are comparatively but very few in which local inflammation does not exist in some organ or structure; and, although in the majority of instances, these inflammations are secondary, or developed after the commencement of the fever, their influence in protracting the disease, and aggravating its phenomena, is, perhaps, not the less con- spicuous. Whenever febrile irritation becomes much protracted or chronic in its course, we may infer, with little chance of mistake, that there exists some obscure focus of inflammation in an internal part. Pure idiopathic or general fever, without the accessory irri- tation of local inflammation, can never continue very long. Mere morbid excitement, from general causes or movable irritants, is gene- rally soon overcome by the organic, or what has been called the sanative actions of the animal economy. CHAPTER X. OF THE PHLEGMASIA OF THE ALIMENTARY CANAL, AND ITS ACCES- SORY ORGANS. Sect. I.—Of Glossitis. Acute inflammation of the tongue is not a frequent disease ; but when violent, it is a very severe, and often rapidly fatal affection. It usually begins with a burning and throbbing pain in the tongue, attended with febrile symptoms, which soon rise to a high synochal GLOSSITIS. 205 grade. The tongue soon becomes hot, dry, red and swollen, the swelling generally increasing rapidly, so that in a few hours it fills almost the whole cavity of the mouth, and is often thrust out between the teeth, appearing like a mass of raw flesh. The respira- tion becomes extremely difficult, and a horrible sense of impending suffocation is experienced. The patient can neither move the tongue nor swallow. In some instances suppuration takes place; and one or more small abscesses are formed in the substance of the tongue, which are seen pointing on some part of its surface at the same time that the pain and swelling subside. Instances have occurred in which mortification of the tongue has taken place, or partial slough- ing of its substance ; and the inflammation has been known to termi- nate in induration of its structure.* The tongue occasionally swells so rapidly and greatly, as to occasion death by suffocation in a very short time. I have known a case terminate fatally in less than twelve hours from the commencement of the disease. More or less inflammation of the tongue generally accompanies laryngitis; and it occurs also occasionally in cynanche tonsillaris; but in instances of this kind, the inflammation and tumefaction of this organ scarcely ever become very considerable. Glossitis may arise from the operation of local irritating causes on the tongue ; such as acrid substances taken into the mouth; wounds; bruises; the sting of an insect; scalding; calculous concretions in the salivary ducts. It may also be produced by atmospheric vicissitudes, or the influence of cold and damp atmosphere. Dr. Hosack relates a case which was caused by sitting in a current of cold air, immediately after being much heated by exercise. Reil states that glossitis has occurred epidemically ;t and Stark has known it to come on periodically, in consequence of suppressed menstruation.^ Treatment.—General blood-letting, promptly and decisively prac- tised, followed by the application of leeches along the margin of the lower jaw, and, if practicable, to the lower surface and extremity of the tongue, are indispensable remedial measures in this affection. Much advantage may also be derived from scarifying the anterior part of the tongue; and still more from making an incision into its substance along the middle. This practice was particularly recom- mended by De la Motte§ many years ago; and in a late number of the Edinburgh Medical and Surgical Journal, an interesting case is related by Mr. Martin, which was successfully treated by incisions. || * Richter's Specielle Therapie. Band. i. p. 497. . t Fieberlehre, torn. ii. p. 411. X Handbuch zur Kennt. und Heil. der innern Krankh., p. 140. \ Med. de l'Acad. de Chirurg., torn. v. II The tongue, in this case, " increased in size until it protruded from the mouth, and separated the jaws. The organ was smooth, hard, and covered with a thick coating of viscid saliva. The patient was bled to 30 ounces, with some relief— and the same quantity of blood was taken in an hour after, which enabled him to articulate distinctly. In three hours more, the swelling had increased—respira- tion through the mouth was impracticable, and that through the nostrils was diffi- 206 CYNANCHE TONSILLARIS. Reil, also, (he. cil.,) speaks strongly in favour of superficial incisions, from an inch and a half to two inches in length, along the middle of the tongue. The bleeding must be promoted by emollient gargles. Richter says that the swelling generally subsides speedily after the incisions; and they readily heal without any disagreeable conse- quences. From the impossibility of swallowing, internal remedies cannot be employed. Laxative enemata, however, are very useful, and should be frequently administered until the bowels are well evacuated. Considerable benefit may also arise from a large blister laid on the back of the neck or on the throat, after proper general and local depletion has been employed. Sect. II.— Of Tonsilitis.— Cynanche Tonsillaris.— Quinsy. In this variety of angina, the inflammation is seated in the tonsils, soft palate, and fauces, and is of a strictly phlegmonous character. In cold and variable climates, it is a disease of frequent occurrence, and although by no means so dangerous a malady as the anginose affections of the respiratory passages, it is much more painful, and in violent cases always alarming, and sometimes fatal. Symptoms.—The disease usually begins with slight chills, suc- ceeded by a high grade of febrile reaction, accompanied with an uneasy feeling in the fauces, and more or less pain in this part on swallowing. In a few hours, a fixed pain is felt about the region of the tonsils, and the act of deglutition becomes more and more pain- ful, until at last it is attended with extreme suffering, or altogether impossible. On examining the throat, one or both tonsils are found very much swollen, and the whole surface of the fauces very red and somewhat tumefied. The tongue also is swollen; white, and covered with a thick layer of transparent viscid mucus. The face is red and tumid; the carotids beat strongly; respiration is difficult; hearing obtuse ; the pulse frequent, hard, and full; and the voice is indistinct or whispering. In general, much more difficulty and pain are expe- rienced in swallowing liquids than soft or pultaceous solids. The pain generally shoots from the fauces into the ears, particularly on attempting to speak or to swallow, and the mouth is opened with great difficulty and pain. A very thick ropy mucus commonly ad- heres to the inflamed parts, and contributes much to the difficulty of respiration. The uvula and soft palate are generally very much swollen; but the principal pain and difficulty of breathing arise from the tumefied tonsils; for when both are inflamed, they sometimes become so much enlarged as to come in contact with each other, con- cult—in short, suffocation was threatened. A deep incision was made in the most prominent part of the right side of the tongue, from whence issued a quan- tity of blood and pus, with evident relief. Two other incisions were made when the first ceased to discharge blood. In a quarter of an hour after the first incision, the patient could articulate distinctly—respiration was free. Next day he was nearly well."—Med. Chir. Rev., October, 1827. XYNANCHE tonsillaris. 207 fining the tumid uvula behind them, or pressing it forwards into the mouth.* The external part of the throat, in the region of the tonsils, is always somewhat tumefied, and tender to the touch. In some in- stances, the tonsils are covered with flakes of coagulable lymph, of a whitish colour, resembling superficial sloughs. Occasionally small excoriations or ulcerations occur on the inflamed tonsils. These ulcers arise from small yellowish pustules bursting and pouring out a lymph-like fluid, which concretes into a whitish pseudo-membran- ous layer on the surface of the tonsil. This, after some time, sepa- rates, and exposes a bright red and very sensible surface or erosion from which a purulent matter is discharged.t The inflammation in this affection terminates either in resolution or suppuration, gangrene being an extremely rare occurrence. In no structure is inflammation more apt to terminate in abscess than in the tonsils. Internal suppuration often occurs in a few days, not- withstanding the most active local and general antiphlogistic mea- sures. The quantity of matter discharged from a suppurated tonsil is seldom so abundant as to become very perceptible in the sputa, a portion of it, no doubt, being commonly swallowed with the saliva. Cases occur, in which the abscess, instead of breaking internally, is gradually enlarged, and extending outwards, points externally under the angle of the jaw.. Dodonoeus relates a case, in which the patient appeared near dying, where speedy relief was obtained by an exter- nal incision into the abscess, and the consequent discharge of a large quantity of pus.J Frequent attacks of the disease are apt to produce permanent enlargement and induration of the tonsils. In some instances the inflammation passes down into the larynx, an occur- rence which always greatly increases the dangerousness of the affec- tion. Causes.—Some individuals are peculiarly predisposed to this variety of angina. This is especially observed in persons who have already once or twice suffered an attack of the disease. The con- stitutional influence of mercury, or salivation, appears to create an increased aptitude to this affection ; a strumous habit, also, appears to constitute a state of predisposition to the disease. The ordinary exciting cause of this complaint is cold and damp air, or cold applied in any manner so as to give a sudden check to the perspiration. Standing long on cold and wet ground is particu- larly apt to give rise to the disease in those who are predisposed to it. It may also arise from local causes, such as irritation from the cutting of one of the posterior teeth; (Sachse, loc. cit., p. 475;) the fumes of arsenic; (Sheffler, von. d. Gesundh. der Bergleute ;) acrid substances, swallowed or applied to the fauces. (Fabricius, cent iv obs. 15.) ' * We may be sceptical, however, with regard to the assertion of Marcellus Donatus, who affirms that he has seen the uvula thus pressed forwards by the swollen tonsils, ad anteriores usque denies.—De Medica Historia Mirabili, p. 84. t Dr. W. Sachse, Encyclopadisches Worderbuch der Medicinischen Wissen- schaften. Band, ii, p. 464. X Obs. Med., p. 192, as quoted by Van Swieten. 208 CYNANCHE TONSILLARIS. Treatment.—The treatment must be vigorously antiphlogistic; and although Cullen asserts that a copious abstraction of blood is seldom necessary, general experience is decidedly in favour of prompt and efficient bleeding in this affection. In slight cases we may some- times subdue the inflammation without blood-letting, but as we can- not be sure, at first, whether the disease will continue a mild course, or acquire much severity, it is always best at once to moderate the momentum of the circulation by depletion. Local bleeding, by scarifying the tonsils, generally produces excellent effects, and may be accounted much more efficacious than the application of leeches to the throat or under the ears.* Cupping on the back of the neck and under the ears, may also be resorted to with benefit. Baglivi asserts that he has known the abstraction of blood, by cupping between the shoulders, afford great advantage in this affection. Internally, pur- gatives and the usual antiphlogistic diaphoretic remedies must be actively employed. An active purge should be one of the first reme- dial measures adopted; the bowels must afterwards be kept freely moved, either by the daily repetition of purgatives, or frequent laxa- tive enemata. A bolus of calomel and jalap, or from fifteen to twen- ty grains of the compound extract of colocynth, with ten grains of calomel, or a full dose of one of the neutral purgative salts, may be used for this purpose. Nitre with antimony, in the usual proportion of the nitrous pow- ders, constitutes the best refrigerant diaphoretic in this complaint. Some advantage may be gained by placing the nitre on the tongue, and swallowing it as it is gradually dissolved in the mouth. The muriate of ammonia, dissolved in water with the extract ofliquorice, has also been particularly recommended.! Much benefit may, in general, be derived from nauseating doses of tart, emetic. I have frequently prescribed this remedy with the happiest effect. A grain of tart, antim. may be dissolved in two ounces of water, of which a teaspoonful is to be taken every half hour, so as to keep up a con- siderable degree of nausea for several hours. Emetics were formerly a good deal employed in this variety of angina, but their effects are much less beneficial in this than in any of the other anginose affections. As soon as the momentum of the circulation has been moderated by venesection, a blister should be applied to the throat, or on the back of the neck. In slight cases of the disease, rubefacients, par- ticularly the spirits of turpentine, or a liniment composed of two parts of ac. ammonias to one of sweet oil, will in general suffice for this purpose. Emollient poultices, also, are very useful applications in simple cases of the disease. When employed as soon as the disease com- mences, together with a warm pediluvium, and a purgative, the further progress of the inflammation will sometimes be speedily and effec- * Kopp, an eminent German physician, says, that blood drawn from the tonsils by scarification, is the best, most certain, and promptest remedy we possess in this affection. tLoeffier. Beitragen zur Arzn. Wissensch. 1 Th. Leips, 1791, p. 142. PAROTITIS. 209 tually checked. In such instances three or four folds of thick flannel round the neck, with the auxiliaries just mentioned, are sufficient fre- quently to prevent the development of the malady. In all instances, however, where the inflammation is considerable, vesication is de- cidedly the most proper. Various gargles and other applications to the seat of inflammation have been recommended in this affection. Cullen advises a decoction of oak bark, with alum dissolved in it, as a gargle in this disease. I have generally preferred using simply warm water, slightly acidulated with vinegar, for this purpose. Little or no advantage results from the use of gargles in this complaint, beyond that of dissolving and removing the viscid mucus which is apt to adhere to the tonsils and palate, and this is best effected by warm water, either alone, or with a portion of some vegetable acid, and perhaps honey. Pringle states that he never derived any benefit from astringent gargles ; and Storch asserts, that he has known them to do very evident harm, by check- ing the exhalation and seeretion from the mucous surface of the in- flamed parts. The inhalation of different vapours is one of the oldest remedies in this disease. Hippocrates used the vapour of vine- gar and water for this purpose. M. Toriac asserts that the application of lunar caustic to the ton- sils in the early stage of this complaint, almost always speedily arrests the inflammation and swelling. He has related several cases, which were completely subdued by this application, in less than two hours. In the case of a lady, whose tonsils were inflamed and so much enlarged as to threaten suffocation, every disagreeable sensa- tion was removed in one hour by the application of the nitrat. argent* When the inflammation has terminated in the formation of a ton- sillar abscess, it should be pierced with a lancet, to give exit to the matter, an operation which always gives immediate relief from the pain and difficulty of respiration. After the pus is discharged, the patient should continue the use of some mild and slightly acidulated or astringent gargle. Sect. III.—Of Parotitis. Mumps. Parotitis is a specific inflammatory affection capable of being pro- pagated by a peculiar contagion, and occurring sometimes epidemic- ally. The disease usually commences with slight febrile symptoms, with a feeling of stiffness of the jaws, and a little swelling and pain either in one or both parotid glands. The swelling gradually in- * The Amer. Jour, of the Med. Sciences, vol. v, p. 212: quoted from La Cli- nique, &c. ' VOL. I.--14 210 PAROTITIS. creases until about the fourth dav from the beginning of the disease, at which time the affected glatid is greatly swollen and very firm and tender to the touch. The skin on the tumour is generally of a natural colour, or but slightly inflamed ; although, in some instances, a pale redness is diffused over the swelling. Mastication and deglu- tition are always attended with considerable pain. The fever is generally mild, "and is often attended with considerable nervous irritability and restlessness. From about the fourth day the swelling gradually subsides until the detumescence is complete, which is gene- rally about, the seventh day. Soon after the inflammation of the parotids begins to decline, the breasts in females, and the .testicles in males, are apt to become much swollen and hard. The subsidence of the disease is usually attended with more or less general diaphore- sis, and a red sediment in the urine. In general, parotitis is neither a severe nor a dangerous affection- more especially when the patient keeps the affected parts moderately warm, and avoids exposing himself to the injurious influence of vari able or low temperature. In some instances, however, a sudden metastasis of the inflammation takes place to the brain, or to the tes- ticles, or the mammae—and this is generally occasioned by the patient taking cold. When it passes to the brain, insensibility, coma, or furi- ous delirium usually supervenes, and death sometimes occurs in a few hours. I have known a case of this kind terminate fatally in less than an hour under a paroxysm of violent convulsions. When the disease thus suddenly falls on the testicles, and the case is not judiciously treated, suppuration of these parts may take place—an occurrence always exceedingly painful, and sometimes ultimately fatal.* The inflammation of parotitis, however, has no tendency to terminate in suppuration ; yet, when circumstances favourable to this termination supervene, it does sometimes take place in the parotids, as well as in the external parts, to which it may be transferred. Children- and young persons are most liable to this affection—its occurrence in middle and advanced age being very uncommon. It very rarely occurs more than once in the same individual, and resem- bles in this respect the other acute contagious maladies. Treatment.—In mild cases, little more is necessary than keeping the bowels open, and using gentle diaphoretics. The parts should be kept warm—great care must be taken to avoid taking cold. When the inflammatory symptoms are violent, an active antiphlogistic treat- ment is necessary. When the swelling disappears in the neck, and shows itself in the testicles, a blister should be laid on the parotids, and every effort made to excite a general diaphoresis. To discuss the hard swelling which sometimes remains after the inflammatory symp- toms have disappeared, frictions on the tumour, with mercurial oint- ment, spirits of camphor, or rubefacient liniments, should be used. * [It is a vulgar opinion, and sometimes a well founded one, that atrophy of the testes is liable to follow a translation of mumps to these organs. One celebrated character was emasculated in this way, and I have known of another case which happened within my own circle of acquaintance.—Mc] % * ACUTE GASTRITIS. 211 Of the Inflammation of the Alimentary Canal. Inflammation of the mucous membrane of the alimentary canal has, of late years, attracted more attention than, perhaps, any other phlegmasial affection. The French pathologists, in particular, have investigated this subject extensively, and most minutely. Whether their peculiar views concerning the connection of this local affection with general fevers, be correct or not, it cannot be doubted, that it is pre-eminently entitled to the attention of the pathologist and practi- tioner. I have already frequently adverted to the great tendency of some forms of fever to give rise to mucous inflammation of the ali- mentary canal; and the practitioner who does not attend to this cir- cumstance, will incur a liability to defeat in his remedial efforts, which cannot be justified in the present state of pathological science. It is, indeed, of the utmost importance, that the medical practitioner should make himself familiar, not only with the general fact just referred to, but especially with the various phenomena, both primary and second- ary, of gastro-enteric inflammation. It is not, however, our purpose, in this place, to treat of this affection in reference to its connection with idiopathic fever. The disease is here considered as a primary affection—the immediate and only cause of the general symptoms which accompany its course, and which necessarily cease with the cessation of the local inflammation, Sect. IV. — Of Acute Gastritis. Symptoms.—Acute inflammation of the mucous membrane of the stomach commences sometimes with violent vomiting and purging, attended with a burning or lancinating pain in the stomach. In some instances, a prickling pain and soreness in the pharynx, without much gastric irritability, are the first symptoms of the disease ; and occa- sionally it begins with great tenderness in the epigastrium, nausea, retching and vomiting. In nearly all instances, frequent and painful- vomiting, especially immediately after swallowing warm liquids, is a prominent symptom. The desire for cool drinks is generally ex- tremely urgent; but the aversion to warm liquids is almost equally strong. After each spell of vomiting, the patient usually experiences a temporary abatement of the gastric distress; and a similar transient alleviation often follows the reception of cool and bland liquids into the stomach. Warm drinks, on the contrary, rarely fail to aggravate the pain and vomiting, as soon as they arrive in the stomach. In some cases, there is a considerable difficulty of swallowing, on account of the contracted and irritable state of the upper orifice of the sto- mach. Oppressed and anxious respiration occurs in many instances, from " the inflamed state of the stomach rendering the descent of the diaphragm painful." (Broussais.) The brain occasionally sympa- thizes strongly with the inflamed stomach. Broussais has seen pa- tients in this disease " as completely delirious as in fevers of the most malignant character, or phrenitis." The delirium, in such instances, 212 ACUTE GASTRITIS. is almost always greatly subdued, for a short time, by a draught of cold water. Acute gastritis is generally attended with great depres- sion of spirits, and prostration of strength ; and the pulse, though at first moderately full, soon becomes very contracted, quick, and tense, and at last so small as scarcely to be felt. A short and painful cough attends in some cases, and the voice usually becomes much altered, and sometimes entirely extinct from paralysis of the laryngeal mus- cles. The aspect of the countenance is expressive of great anxiety and suffering, or of despondency and despair. When the inflammation is confined to the stomach, the bowels are constipated; but where the colon becomes involved in the disease, diarrhoea, or tenesmus, with dysenteric discharges, attends. The skin is dry, and generally hot; and the tongue often red and clean, or co- vered with a thick layer of white fur along the middle, with a red and granulated border. Towards the conclusion of fatal cases, hiccough, faintings, cold extremities, slight delirium, coma, and cold, clammy sweats occur. Such are the more prominent symptoms which usually attend this affection. Acute gastritis does not, however, always manifest itself by these unequivocal phenomena. In some instances, the inflam- mation is developed and proceeds to fatal disorganization; in so obscure and insidious a manner, as to present scarcely any of the ordinary manifestations of its existence. Dr. Abercrombie* justly observes, that the symptoms which attend acute inflammation of the stomach, are liable to great uncertainty. The records of medicine furnish us with many instances, in which the most striking traces of previous inflammation were detected in the stomach on post-mortem examination, but which exhibited none of the symptoms by which the presence of this affection is usually ascertained. I have recently met with a case, in which the patient complained of intense pain in the head, with occasional slight delirium, transient darting pains through the chest, nausea, with an indescribable feeling of distress in the epigastrium ; a frequent, firm, and contracted pulse; but without any actual pain in the stomach, or other symptoms that could be regarded as characteristic of gastritis. The patient, in the course of five days, sunk under his malady. On post-mortem exami- nation, nearly the whole internal surface of the stomach was found minutely injected, and large patches of the mucous membrane were softened, abraded, and, in some parts, very conspicuously thickened, and of a yellowish ash-gray colour. No other local affections, whether in the abdomen, thorax, or head, were noticed. Diagnosis.—Acute gastritis, in its ordinary developed character, may be distinguished from cramp and flatulent pains by the follow- ing distinctive circumstances. In gastritis, the pulse is small, tense, and quick; in spasm, or flatulent pains, it is generally full, or nearly natural. In gastritis, violent vomiting generally occurs, particularly after taking warm fluids into the stomach. In spasm, vomiting * Pathological and Practical Researches on the Diseases of the Stomach. Edinburgh, 1828. ACUTE GASTRITIS. 213 rarely takes place, and warm drinks do not readily excite or aggra- vate it. The pains seldom intermit in gastritis, except immediately after taking some cool and bland fluid into the stomach, or for a few moments after vomiting. In spasm the pain often intermits wholly for several minutes, independently of the effects of cool drink or vomiting. In gastritis, the patient almost always lies on his back, and moves himself as little as possible. In cramp, he sits up or walks about, with the body bent forwards, or throws himself about on the bed. The pain in gastritis is burning and lancinating; in spasm, it is heavy, twisting, aching and extremely severe. In gas- tritis, the skin is hot and dry; in spasm, it is usually moist, and rather cool. In gastritis, finally, pressure on the epigastrium is attended with a sense of great soreness, and an increase of the pain; in cramp, pressure generally affords some relief from the violence of the pain. Causes.—Substances, of an irritating or corroding character, re- ceived into the stomach; cold water rapidly swallowed when the body is heated, and in a state of free perspiration from fatiguing exercise; over-distension of the stomach by stimulating or indigesti- ble food; stimulating drinks; the external application of cold; the suppression of habitual sanguineous discharges; metastasis of rheu- matism and gout; external mechanical injuries of the epigastrium ; —all these causes may give rise to acute gastritis. Besides the foregoing manifest causes of acute gastritis, there are others of an occult character which appear to possess a specific tend- ency to excite inflammation of the stomach. Of these, the miasm which produces yellow fever is the most remarkable. Acute gastritis occurs, also, very frequently, in other forms of malignant fevers, par- ticularly in the putrid typhus of warm climates. Prognosis.—A gradual subsidence of the pain, and disposition to vomit, accompanied with a lateritious sediment in the urine, spon- taneous feculent alvine discharges, a gentle moisture of the skin, and a more developed compressible pulse, indicate a favourable termina- tion. When, on the contrary, the pain and vomiting continue with unabated violence for several days, with difficulty of respiration and hiccough, the pulse becoming smaller, more frequent, and corded, the worst consequences are to be dreaded. If, after the symptoms have continued in this progressive course of aggravation, the pain sud- denly subsides, and the extremities become cold and clammy, with dimness of sight and slight delirium, a fatal termination is inevitable. Post-mortem appearances.—In some instances of great violence, the disease proves fatal before gangrene or disorganization has taken place in the inflamed mucous membrane. Broussais thinks, that in such cases death takes place " from the sole effects of pain, and before the inflamed texture is broken down or sensibly altered in its composition. Those who had died in the early stage of the com- plaint, frequently showed nothing more on dissection than discolora- tion, without erosion or ulceration of the mucous membrane." In the majority of fatal cases, however, the mucous membrane presents strong marks of disease. It is frequently thickened, dense, and minutely injected, " exhibiting the character of ecchymosis;" erosion 214 ACUTE GASTRITIS. and ulceration also are a common occurrence, and in many cases different parts of this membrane are in a softened or broken down state, and of a pale yellow or dark brown colour. Treatment.—Bleeding here, as in the other phlegmasial affec- tions, stands at the head of our remedial means. The smallness and frequency of the pulse must not deter the practitioner from the use of the lancet. On the contrary, when the existence of acute gastric inflammation is unequivocal, this contracted state of the pulse ought to be regarded as the most urgent indication for prompt and copious depletion. In general, all the symptoms remit after an efficient abstraction of blood. The remission, thus procured, is, however, seldom of long duration—an exacerbation usually coming on in an hour or two, demanding a repetition of the use of the lancet.* Next in importance to prompt and copious bleeding, is the application of leeches, followed by a large blister over the epigastrium. When leeches cannot be had, a vesicatory, sufficiently large to cover the whole epigastric region, should be at once applied ; for as four or five hours must elapse before the blister can inflame the skin, sufficient time is allowed to moderate the momentum of the circulation, and the general phlogistic state of the system, by prompt and copious depletion, to obviate any injurious consequences from the general stimulating effects of the blister. The blister should be dressed with mercurial ointment. The ordinary internal antiphlogistic remedies, such as nitre, anti- monials, and cathartics, are entirely inadmissible in this affection. Considerable advantage may be obtained from the free use of mild mucilaginous drinks, such as flaxseed tea, infusion of althea, or of marsh-mallows, or of the common malva rotundifolia of this coun- try, thin barley-water, or a solution of gum arabic in water. I have used an infusion of the slippery-elm bark, in a few instances, with much apparent advantage. The vegetable acids, diluted with some bland mucilaginous fluid, sometimes relieve the gastric distress con- siderably, more especially the lemon-juice. Broussais says, that " orange-juice diluted in water forms an excellent drink in this dis- ease." The mineral acids are alway injurious. Costiveness must be obviated by laxative enemata; and this should be particularly attended to, throughout the whole course of the disease. For this purpose, we may use the following: &.—01. ricini ^ij. Sapon. venet. tjj. Infus. sem. lini^viij.—M. fiat enema. Opium is a valuable remedy in this affection. After the general * Broussais does not seem to place a great deal of reliance on the employment of venesection in this affection. "La saignee," he observes, "n'eteint point un phlogose de Festomac, comme elle emporte un peripneumonie, et qu'elle est inutile sans le concours des emolliens. J'ai eu assez lieu de me convaincre que les evacuations sanguines sout'd'un bien faible secours dans les inflammations des organes plats et membraneux, lorsqne ces tissues ne sont point appliques surunparan- chyme.''—Phlegma?, Chron., vol. ii. p. 20. CHRONIC GASTRITIS. 215 phlogistic condition of the system has been considerably moderated by venesection, full doses of opium rarely fail to allay the pain and vomiting, and to excite a general and salutary action of the cutaneous exhalents. " Opium," says Dr. Armstrong, " when given in health, constipates the bowels; but this is so far from being the case in gas- tritis and enteritis, that it tends to assist the action of purgatives, and, when exhibited in conjunction with proper depletion, it may be fairly accounted one of our best remedies. The two most remarkable effects of full doses of opium in gastritis, are relief of the pain and reduction of the pulse; so that the patient often falls asleep shortly after their exhibition, and the pulse which had been previously small and quick, will become full and small." Some writers recommend the use of this narcotic in combination with calomel in the present disease. " Pills, with a grain of calomel and a grain of opium, ad- ministered three or four times daily, will be found sometimes to allay pain and arrest inflammatory action in acute gastritis."* I have myself sometimes employed this combination with great advantage. When opium is employed in this affection, it ought to be given in large doses, and repeated so as to keep up a continued impression on the system. In two of the most decided cases I ever saw, two grains of opium were administered every three hours, until eight grains were taken, and with the happiest effects. Efficient blood-letting, both general and local, should always be premised to the employ- ment of this .narcotic! During convalescence from this disease, the utmost care is neces- sary to avoid taking solid and stimulating articles of food and drink. Nothing but the blandest liquid nourishment should be allowed— such as oat-meal gruel, boiled milk, barley-water, beef or chicken- tea, or preparations of arrow-root, sago, rice, or tapioca. Sect. V. — Of Chronic Gastritis. Chronic inflammation of the mucous membrane of the stomach is one of the most common phlegmasial affections. The worst forms of dyspepsia, and all that host of inveterate gastric and bilious dis- orders of which so much is heard, and the true nature of which is so *A Compendium of Theoretical and Practical Medicine. By David Uwins, M. D., 1828. t [I have lately been called into consultation in two distressing and dangerous cases of acute gastritis—in both of which speedy and permanent relief was afforded by the administration of full doses of the nitrate of silver. Half a grain was given in a pill with one grain of ext. Hyoscyami at short intervals, until every symptom was allayed. In the case of a lady, whom I attended with my brother, Dr. Samuel McClellan and Dr. Shallcross of this city, immediate relief was afforded to the most painful and incessant vomiting, and a long-continued sense of a lump of red-hot iron on the stomach. This patient had begun to sink into hopeless prostration and coldness, and actually threw up considerable quantities of the real black vomit in the course of her attack.—Mc] 216 CHRONIC GASTRITIS. often misunderstood, are in nine cases out of ten the consequences of a chronic inflammatory condition of the lining membrane of the stomach. The slow and insidious progress of this grade ot gastric inflammation during its early period, is indeed well calculated to elude observation, and to lead to a misapprehension ol its true cha- racter. In many cases the first symptoms are those which usually characterize indigestion—such as acidity, flatulence, a sense ot heavi- ness and oppression after eating, eructations, and transient slight pains in the region of the stomach. When the stomach is empty the patient feels easy, but generally languid and dissatisfied, and often tormented with a craving and capricious appetite for food. As the disease advances, the epigastrium becomes somewhat tense, and sore to the touch, and nausea or vomiting is apt to occur an hour or two after taking food. The gastric distress gradually becomes more and more troublesome, particularly after eating; the patient complaining of a constant distressing sensation, amounting sometimes to actual pain in the epigastric and right hypochondriac region. The pain in the stomach is generally confined to a circumscribed spot, and is of a lancinating and stinging character. A sensation of pressure against the diaphragm, as if by a large ball, is occasionally experienced by some patients, whilst others complain of a feeling as " if a bar were fixed across the stomach, preventing the passage of food or drink into the stomach." (Broussais.) In some instances, a fluid resem- bling the white of eggs is copiously thrown up from the stomach, and many complain of a constant and most painful feeling of pyrosis. (Abercrombie.) Andral mentions a case in which four pints of a glairy fluid were thrown up every twenty-four hours, without any portion either of the food or drinks she took coming off with it. In the advanced periods of the disease, the appetite almost always fails entirely, and in very aggravated cases " there is a general abhorrence of food." Costiveness almost universally attends the disease in the first periods of its progress ; but in many instances diarrhoea ultimate- ly ensues, accompanied with tormina, and sometimes with mucous and bloody stools, and more or less tenesmus. The patient is gene- rally dejected, morose, impatient, of an irritable temper, and "but little disposed to enter into a detail of his sufferings." In general, the cheeks and prolabia are of a deep red colour, the tongue is often clean, smooth, and of a vermilion tint over the whole anterior sur- face, or red and granulated," somewhat like the points upon a straw- berry, with deep fissures, or covered with a streak of brown fur along the middle, with red and clean edges." In the advanced stage of the disease, emaciation always goes on rapidly, the cellular and adipose structures becoming almost entirely absorbed; in inveterate cases the skin is brown, inclining to yellow, and is drawn tightly over the mus- cles, sinking into their interstices, so as not to be pinched up without much difficulty, even where it usually is most relaxed. (Broussais.) In some instances a slight cough attends, but the function of respira- tion is rarely much disturbed. The pulse is generally quick, and more or less tense, though not often accelerated in the beginning, except soon after eating; but in the latter periods it becomes con- CHRONIC GASTRITIS. 217 tracted, hard, and frequent. There generally exist much muscular prostration, and great indisposition both to bodily and mental exer- tion. The disease often continues for many months, gradually ac- quiring strength as it advances, until the system becomes exhausted under a wasting and slow irritative fever, and life is extinguished. Chronic gastritis is not always marked by symptoms so conspicu- ous as to render its existence very obvious. The inflammation some- times proceeds in so obscure a manner as to terminate in fatal disor- ganization, with scarcely any accompanying manifestations of a serious import. I attended a child which appeared to labour only under tri- fling gastric derangement, with occasional slight febrile exacerbations. Death occurred unexpectedly in the third week of its indisposition; on dissection, a large circular spot of the mucous and muscular coats of the stomach was entirely softened and broken down, and of a yellowish-gray colour. Andral has related several cases illustrative of the insidious progress of this malady. In one case no suffering or uneasiness in the stomach was complained of by the patient until eighteen hours before death. In some cases, after a few weeks, or perhaps months, of slight un- easiness in the stomach, sudden vomiting with prostration and vio- lent pain in the epigastrium occurs, and speedily terminates in death, under symptoms of peritonitis, in consequence of the unsuspected inflammation in the stomach perforating its coats, and giving exit to its contents into the cavity of the abdomen. When the inflamma- tion terminates in perforation of the stomach, death generally occurs from the sudden supervention of peritonitis. In such cases, after an indefinite period of gastric disturbance, sudden and extremely severe pain occurs in the epigastrium, attended by vomiting or retching, " as if some acrid poison had been taken into the stomach." Chronic gas- tritis is frequently connected with more or less phlogosis of the supe- rior portion of the intestinal tube. Causes.—Chronic gastritis may be the consequence of the acute form of the disease ; but it is much more commonly the result of irri- tating substances acting immediately on the internal surface of the stomach;—such as indigestible, heating, or irritating articles of food and condiments ; acrid medicinal substances ; insufficient and innutri- tions articles of food, in conjunction with habitual exposure to damp and cold situations, or mental despondency; the intemperate use of alcoholic liquors ; repelled cutaneous eruptions ; suppressed habitual discharges ; neglected or ill-managed dyspepsia. The depressing mental emotions, if they do not actually excite the disease, are among the most powerful predisposing causes of this distressing malady. The united influence of despondency and crude innutritious food appears to be peculiarly apt to give rise to this grade of gastric inflammation. The development of the disease is often very gradual, commencing in mere debility of the digestive powers, which, without great attention to dietetic rules, leads to irritation, and finally to chronic inflammation of the internal surface of the stomach. Over-distension of the stomach by food or drink, especially when 218 CHRONIC GASTRITIS. habitual, and when the ingesta are of a stimulating character, is a common source of this affection. Diagnosis.—In its early periods, chronic gastritis may be readily mistaken for dyspepsia; for its symptoms often differ but little from those which occur in the latter disease. When, however, the patient feels considerable pain in a particular spot, followed by vomiting soon after eating, and a severe feeling of pyrosis attends, with redness and tenderness of the tongue and throat, and the patient becomes much weakened and emaciated, we may reasonably suspect the existence of chronic gastritis. Considerable difficulty often exists, in distinguishing chronic gas- tritis fromgastralgia—a neuralgic affection wholly unconnected with inflammation. There can exist no doubt that this malady has been frequently mistaken for chronic gastritis; and as the modes of treat- ment appropriate to each are diametrically opposite, it is manifestly of the utmost importance to learn to distinguish them from each other. Mr. Barras has published some interesting observations on gastral- gia, and on its liability to be mistaken for chronic gastritis. He gives the following, among others, as diagnostic symptoms between these two affections.* 1. " In chronic gastro-enteritis, the pain is generally obtuse ; often felt only on pressure ; is never absent. Gastralgic pain, on the other hand, is often extremely violent; is often, when most violent, relieved rather than increased by pressure. It often radiates from the epi- gastrium towards the thoracic parietes, the back, and the shoulders; is of an intermittent character, sometimes entirely disappearing, to return with more or less violence. 2. " In chronic gastritis, the tongue, which is generally red on the sides and at the tip, is covered in the middle with a kind of dry mucous crust, resembling a false membrane ; the breath is fetid, with a bitter taste in the mouth; there is thirst. In gastralgia the tongue is white; saliva abundant; no thirst, but sometimes a repugnance even to liquids. 3. " In gastritis, the appetite is always bad, and sometimes amounts to a universal disgust for every kind of food. In gastralgia, the appetite is variable, null, slight, natural, often greater than in health. 4. " In chronic gastritis, the ingestion of a small quantity of food renews the patient's sufferings ; excites as a febrile movement in the system, and the digestion is always imperfect. There is often rejec- tion of the food by vomiting a little time after eating; or if there be no vomiting, the patient is oppressed, during the digestive process, with a sense of weight, distension, nausea, acid, or acrid eructations, and irritation of the bowels, or diarrhoea, in the advanced stages. In some cases of gastralgia, the pain is relieved, at least for a time, by eating food in considerable quantity, and the digestion is complete, or even too quick. In most cases of gastralgia, however, the presence of food in the stomach renews the pain; but not till some time after eating; generally, one, two, or even three hours; at which time the pa- * Revue Medicale, November and December, 1825 CHRONIC GASTRITIS. 219 tient experiences weight and malaise at the epigastrium, as if a foreign hody were lodged in the stomach. There are nausea, borborygmi, flatulent colic, eructations of air, but without fetor or causticity. Sometimes, indeed, patients will taste the aliments that they have swallowed in the air which they eructate, but the digestion is com- pleted, and diarrhoea is very rare. Constipation is generally obstinate, and the urine, especially when the gastralgia is in a high degree, is usually pale, voided frequently, and in small quantities at a time. 5. " Chronic gastritis never fails to impair the process of nutrition, inducing hectic fever, characterized by hardness and frequency of the pulse, heat of the skin, and evening exacerbations, with loss of flesh and strength, sallowness of the countenance, with a peculiar dark tinge, and finally death. 6. " In some violent and prolonged cases of gastralgia, the pa- tient experiences difficulty of breathing, palpitations of the heart, wandering pains, and peculiar sensations of coldness, especially in the arms, loins, and lower extremities. The sleep is sometimes good, sometimes agitated, sometimes null; yet, in the mornings, the patient gets up refreshed, and feels quite well, till breakfast renews the gas- tric sensibility. Nothing of this kind obtains in latent gastritis. 7. " Those who are affected with chronic inflammation of the di- gestive tube are melancholy, morose and impatient; but this is nothing to the state of moral depression and anxiety which obtains in gastral- gia. In this last, there is ineffable despondency; disgust of life, or fear of death in the extreme ; the slightest sensation in the stomach awakens the patient's terrors; he is tremblingly alive to every look of his physician—to every word which is spoken by his friends re- specting his complaint; he is afraid of taking any thing into his sto- mach, as he knows, by doing so, he will aggravate the complaint; he is convinced that his disease is mortal—becomes entirely absorbed by his own sensations, and indifferent to every thing else. But any diminution or sensation of the gastralgia immediately changes the scene from despair to sanguine hope—to be again reversed on the slightest accession of pain." Dr. Armstrong observes, that the effects of a diffusible stimulus— such as wine, brandy, &c, will generally remove all doubts as to the presence of the one or the other of these affections. In gastritis, the pain and uneasiness in the stomach are always increased by potations of this kind; whereas, in gastralgia, relief is generally the result.* Whenever fever, pain, and anorexia occur after the operation of an emetic we can no longer doubt the existence of chronic gastritis. (Broussais.) Post-mortem appearances. The organic changes effected in the stomach by chronic inflammation of its villous coat, are very various. In almost all fatal cases, more or less ulceration is found in the stomach; and these ulcers exist in various forms and stages of progress. Some- times a single ulcer, not above a quarter of an inch, occurs, the other * The Morbid Anatomy of the Bowels, Liver, and Stomach. Fasciculus, i and ii, London, 1828. 220 CHRONIC GASTRITIS. portions of the mucous membrane being in a healthy condition. Oc- casionally, we find various ulcers—some partly cicatrized, others just beginning, and others again, deep with loss of substance, and rounded and elevated edges. When the ulcerated surface is large, there are " generally thickening and induration of the coats and fungoid eleva- tions." (Abercrombie.) Sometimes the only organic lesion consists in a thickening of the mucous membrane, in different parts of its extent, of a pale ash, or brown, or dark colour resembling melanosis. In other instances, portions of the mucous membrane are softened or broken down, or entirely destroyed.* Cases occur, however, in which no organic changes whatever are detected in the.mucous membrane on dissection. In instances of this kind, the subjacent cellular tissue, says Andral, is found in a diseased state—and this is particularly ob- servable in that condensed and whitish membrane between the villous and muscular tunics of the organ. (Med. Chir. Rev.) Andral observes, that thickening and induration of the mucous membrane, are one of the most certain marks by which chronic may be distinguished from acute gastritis. Softening of this membrane, is, however, the most frequent of all the organic changes effected in this disease.t In some unequivocal cases of chronic gastritis, M. Andral found nothing but stripes of thickened and condensed mucous membrane, and of a paler colour than natural. In one very strongly-marked case, nothing but a patch of a milky white colour, with slight thickening and induration of the mucous membrane, was discovered on the stomach on dissection. Treatment.—In the treatment of this variety of gastric inflamma- tion, almost every thing depends on proper dietetic regulations. It is obvious, that every thing which tends to irritate the stomach, must be particularly calculated to favour the progress of the disease, and to aggravate the sufferings of the patient. It is, therefore, of the utmost importance in the remedial management of this affection, to allow nothing in the way of nutriment, but the blandest and least irritating articles of diet that can be contrived. Mucilaginous liquids, such as decoctions of barley, rice, thin gruels, and fluid preparations of arrow-root, tapioca, or sago, or boiled milk, and animal jellies, constitute the appropriate nourishment for patients affected with this disease. All solid articles of diet should be especially avoided. Leeching or cupping over the region of the stomach is another of our most efficient means for subduing this distressing affection. Much benefit will also sometimes accrue from the application of a blister to the epigastrium; or, what has appeared to me still more useful, frictions with tartar emetic ointment, until pustulation is pro- duced. Leeching and blistering should be used, from time to time, in alternation. * Pathological and Practical Researches on Diseases of the Stomach, &c. By John Abercrombie. t Memoir sur les Caracteres Anatomiques de la Gastrite Chronique. Par M. Andral, Repertoire Generate, Nos. 1 and 2, 1824.—See Med. Chir. Rev., Jan. 1827. ACUTE ENTERITIS. 221 Among the internal remedies useful in chronic gastritis, the sulph. ferri is, probably, the most valuable. Dr. Abercrombie speaks very favourably of its effects in this complaint—and Dr. Armstrong re- commends it as a remedy of considerable value. Within the last two years, I have employed it in several cases with very decided advantage. Dr. Abercrombie administers it in doses of two grains, with a few grains of aromatic powder, twice or thrice daily. I have never given more than one grain at a dose, and indeed very seldom more than half a grain. It has appeared to me most beneficial when given in union with the extract of hyoscyamus. Haifa grain of the sulphate with a grain of this narcotic, and an eighth of a grain of sulph. morphia, maybe given four times in the course of twenty-four hours. I have, also, employed the nitrate of silver, in small doses, with very evident benefit in cases of this kind. It should be adminis- tered with a considerable portion of some bland mucilaginous fluid. In a case for which I lately prescribed, very excellent effects were obtained from the use of five grains of powdered borax, in union with four grains of Dover's powder, three times daily. Balsam copaiva has been particularly recommended in chronic inflammation of the alimentary canal. In small doses, I have used the following mixture, in a few well-marked cases of this complaint, with consider- able benefit. R.—Bals. Copaiv. ^iss. P. g. arab. 3ij. Syrup, limonis ^ss. Aq. fontanse 3 viij. Tinct. opii acetat. gtt. 30.—M. S. A small tablespoonful twice daily. To palliate the distressing sensations in the stomach, as well as the general irritability both of mind and body, two or three grains of Dover's powder may be given at night on going to bed. For this purpose I have employed the lupuline with much benefit. From four to sfx grains of this preparation may be given once daily. The syrup of poppies may also be advantageously used, as an occasional anodyne in this affection.* Care must be taken to procure regular alvine evacuations. This, however, cannot be prudently effected by laxatives taken into the stomach; for however mild they may be, they will almost inevitably do mischief by irritating the morbid mucous membrane of the stomach. One or two purgative enemata, administered at stated hours daily, rarely fail to procure all that may be desired in this respect. Sect. VI.— Of Acute Enteritis. Acute inflammation of the intestinal canal occurs under two forms, sufficiently distinct in their pathological characters and phenomena, to require separate consideration. In one of these varieties, the in- flammation is seated chiefly, perhaps in some instances exclusively, * [The nit. arg. is infinitely the best remedy in this state.—Ma] 222 acute enteritis. in the peritoneal and muscular coats of the intestines; and in the other, the inflammation is confined wholly, or in a great measure, to the internal or mucous membrane. In the first, constipation is almost universally present; in the second, mucous discharges, with more or less blood and tenesmus, are rarely absent. 1. Acute Peritoneal Enteritis. Symptoms.—This disease often commences with a feeling of un- easiness in some part of the abdomen, terminating, after a longer or shorter period, in a fixed aching or burning pain, referred usually to the umbilical region. In some instances, the pain is confined to a circumscribed part; but it more frequently becomes diffused through- out the whole abdomen. Obstinate constipation almost invaria- bly exists—except the inflammation extends to the mucous mem- brane of the colon or rectum, which, however, occurs but very rarely, when dysenteric discharges, with tenesmus and tormina at- tend. Nausea and vomiting are frequent and very distressing at- tendants on the disease; the latter often becoming so constant and violent as to communicate the inverted action of the stomach to the bowels, causing stercoraceous matter to be thrown up. The tongue is dry, and generally covered with a white fur, sometimes of a pale red round the edges, with a streak of brown fur along the middle ; the thirst is urgent; the urine scanty, high coloured, and frequently discharged with considerable difficulty; the skin hot and dry on the trunk of the body, but often moist on the forehead and in the palms of the hands ; the pulse small, frequent and tense; and the respira- tion almost always more or less disturbed—being usually short, anxious, and performed by the action of the intercostal muscles ex- clusively. To avoid pain from the pressure of the abdominal mus- cles on the inflamed bowels, the patient lies on his back, with the knees drawn up, and the shoulders raised by pillows, by which the tension of these muscles is diminished. Sometimes acute peritoneal enteritis is ushered in " by a sort of rigor," exhibiting, in its subse- quent course, two distinct stages—one of excitement, and the other of collapse, resembling, in this respect, acute peritonitis. In the stage of collapse, the extremities become cold, and at last damp, " while the fingers and hands are generally mottled by a dun sort of redness here and there." The pulse becomes weaker and weaker, until it feels under the finger " like a soft undulating line." Great prostration of the muscles exists ; the "face becomes death-like ; the abdomen tumid and tense;" and, lastly, a sort of passive gulping generally takes place, the contents of the stomach being apparently forced up the oesophagus by the pressure of the intestines, which are then, for the most part, enormously distended with flatus.* Peritoneal enteritis is generally rapid in its course, and is peculiarly prone to terminate in gangrene. When this termination is about * Armstrong's Morbid Anatomy of the Bowels, Liver and Stomach, &c. acute enteritis. 223 taking place, the pain suddenly subsides; the pulse sinks rapidly, the countenance becomes pale and cadaverous; the extremities cold ; the surface covered with a cold clammy sweat, and hiccough, slight delirium, and occasionally convulsions, close the scene. This affection is seldom protracted beyond the seventh or eighth day, without termi- nating either in resolution or in death. Diagnosis.— When the inflammation is seated in the arch of the colon, peritoneal enteritis may simulate pleuritis or hepatitis. From these affections it may be distinguished by the foljowing circum- stances:-In pleurisy, the pulse is full, hard, and active-in enteritis, it is contracted, corded, quick, tense, and frequent. In pleurisy, the respiratory motion of the thorax is not conspicuous, the act of respira- tion being performed wholly by the diaphragm and the abdominal muscles-in enteritis, on the contrary, the chest is regularly and strongly dilated and contracted by the action of the intercostal mus- cles whilst the abdominal muscles and the diaphragm are quiescent. In pleurisy, the pain is aggravated by pressure on the intercostal spaces but abdominal pressure causes little or no suffering-in ente- ritis, the reverse obtains, abdominal pressure causing much aggrava- tion of the pain, whilst pressure on the intercostal spaces gtves no particular uneasiness. « From simple peritonitis, enteritis differs by the presence of vomit- ing, and obstinate constipation of the bowels. The pulse also is more permanently frequent, and the pain more violent and constant often resembling the tormina of ileus."* From spasmodic pain of the bowels, enteritis is readily distinguished by the following signs :—In enteritis, the patient lies quietly on his back, moving himself as little as possible-in colic, he throws himself about almost continually. In enteritis, abdominal pressure aggra- vates the pain—in colic it often relieves it. In the former affection the pain is continuous-in the latter, it frequently intermits entirely for a short period. The skin, in enteritis, is hot and dry-in colic, it is seldom above the natural temperature, and generally moist. In colic there is rarely any thirst—in enteritis almost always. It has already been stated that in the present variety of enteric in- flammation, the chief, and sometimes perhaps the exclusive seat of the disease, is in the external peritoneal covering of the intestinal canal, though the muscular coat, no doubt, very generally participates in the inflammation. In some cases, it would seem, the inflammation commences in the internal or mucous membrane, and after a longer or shorter period, leaves this structure to fix itself on the muscular and peritoneal tunics. (Armstrong ) The existence of obstinate constipation in enteric inflammation may be regarded as a pretty certain sign that the disease is seated in the peritoneal and muscular coats of the bowels, or in one or the other of these tunics separately. Abercrombiet asserts, that in peri- * Abercrombie on the Diseases of the Stomach, &c. t Pathological and Practical Researches on the Diseases of the Intestinal Canal Edinburgh, 1828. 224 ACUTE ENTERITIS. toneal enteritis, the peristaltic action of the bowels is not particularly affected; and that, whenever obstinate resistance to the operation of purgatives exists, the muscular coat is the seat of the inflammation. This does not entirely accord with general experience ; for, it is well known, that constipation is scarcely ever absent in every variety of peritoneal inflammation. Without doubt, inflammation of the mus- cular coat will always be accompanied with more or less inactivity of the bowels; but the mere absence or presence of constipation cannot be viewed as distinctive of muscular and peritoneal inflam- mation in enteritis. It is, indeed, probable that peritoneal and mus- cular inflammation are almost always concomitant in this affection ; and all attempts to assign appropriate symptoms to each separately, must be fallacious, and, indeed, of no practical usefulness whatever. Nevertheless, the presence of costiveness or diarrhoea affords us a good diagnostic between mucous and peritoneal, or peritoneo-muscu- lar inflammation in enteritis. " In proportion as the force of the in- flammation is directed upon the peritoneal and muscular coats of the intestines, constipation prevails ; and, on the contrary, when irrita- tion or inflammation is seated in the mucous membrane, diarrhoea or dysentery obtains." (Dr. James Johnson.) Post-mortem appearances.—The only favourable termination of peritoneal enteritis is in resolution—and this termination is frequently attended by a moderate diarrhoea. Suppuration is a rare occurrence in this affection. I have lately, however, met with an instance in which this termination occurred. Its most common fatal termina- tion is in gangrene. But it would seem from the observations of pathologists, that this disease sometimes terminates fatally, without the occurrence either of suppuration, effusion, or gangrene, or with- out any perceptible structural changes, (Wilson, Broussais, Aber- crombie,) and merely " from the general irritation and lesion of function." In some cases of extensive inflammation of the external tunic of the bowels, coagulable lymph is thrown out, and adhesions formed between the different folds of the intestinal tube, so as to agglutinate the bowels in some instances, into a round and firmly adherent mass. This mode of termination is usually accompanied by more or less of a sero-purulent fluid in the cavity of the abdomen, attended some times with masses of a fatty substance resembling soft butter, depo- sited in the cavities formed by the folds of the intestines—an instance of which occurred not long since to Dr. Hartshorn and myself. Causes.—Peritoneal enteritis may be produced by an accumula- tion of indurated feces in the bowels; by spasm; external mechanical injuries ; hernia ; drastic purgatives; sudden suppression of perspira- tion from cold ; standing long on cold and damp ground; metastasis of external inflammations, of gout—rheumatism, erysipelas, &c; intus- susception, worms, wounds, &c. Prognosis.—This disease is always to be regarded as one of very considerable danger. A very contracted or scarcely perceptible pulse, attended with cold hands and feet; or an extensive diffusion of the ACUTE ENTERITIS. 225 pain throughout the abdomen, more especially when at the same time, the abdomen becomes tumid, tense, elastic, and extremely tender to pressure, indicates great danger. Very frequent and violent vomit- ing is also a very unfavourable sign ; for, independent of the additional irritation and suffering which it causes in the inflamed structures, it contributes, in no small degree, to increase the general prostration, and prevents, moreover, the retention of both remedial and nutritient articles into the stomach. Hiccough, in the early period of the dis- ease, is not indicative of particular imminent danger; in the advanced stage it comes in the train of fatal symptoms, manifesting the super- vention of gangrene. An expanded state of the pulse may be re- garded as a favourable sign — the degree of violence and danger corresponding generally with the degree of contraction and obscurity of the pulse. After all, the prognosis in this affection is always attended with much uncertainty. I have seen patients recover from this disease after most of the above unfavourable symptoms had made their appearance; and, on the contrary, several deaths have occurred from this affection, in my practice, most unexpectedly, when no particular unfavourable symptoms were present. Treatment.—In the commencement of the disease, prompt and efficient blood-letting is the remedy upon which our hopes of success must be mainly placed. The first bleeding should be carried to the extent of producing a decisive impression on the system. After the violence of the disease has been thus checked, smaller bleedings should be repeated from time to time, so as to keep up the impression made by the first. The success of medical treatment in this affection depends in a great measure on promptly breaking down the violence of the inflammation during the first twenty-four hours, and nothing can contribute so much to this desirable effect, at this early period of the complaint, as efficient blood-letting. Writers have expressed different opinions with regard to the utility of local bleeding by leeches, in this, as well as in other acute inflam- mations within the cavity of the abdomen. Abercrombie observes, that " leeches are entitled to no confidence, except when the affection is limited, or the strength unable to support constitutional measures." In the beginning of the disease, little or no advantage will result from this mode of depletion, but after the violence of the inflammation has been subdued by decisive venesection, leeching over the seat of the pain is unquestionably a very important auxiliary. The removal of blood in this way must at least tend to sustain the antiphlogistic impression made by the previous general bleeding, and it may be practised with advantage where the propriety of further venesection may be doubtful. Purgatives, under proper management, are decidedly useful in this affection. The more drastic articles of this kind, however, should be avoided, as they rarely procure adequate evacuations, and frequently do mischief by exciting much sickness, vomiting, and tormina. In two instances of this disease, reported by Dr. Aber- crombie, a relapse was the consequence of the use of drastic purga- tives. He thinks himself warranted, from the results of his expe- vol. i.—15 • 226 ACUTE ENTERITIS. rience, to conclude that purgatives are apt to prove detrimental in the early period of enteritis, and in this opinion Dr. Johnson seems inclined to agree with him. In the early stage of the disease, laxa- tive enemata ought to be used; and I have known considerable advantage derived from the copious injection of warm water, ren- dered slightly mucilaginous by starch or flaxseed, into the bowels. Laxatives of the milder kind, when judiciously managed, are, how- ever, not only perfectly harmless, but generally unequivocally bene- ficial in this malady. But even these should not be administered until a strot.g impression is made on the system by blood-letting. After proper depletion has been made, the intestines ought undoubt- edly to be evacuated by the administration of laxatives; and for this purpose calomel, with castor oil and opium, will generally answer perfectly well. Two grains of opium, with five or six grains of calomel, may be given every two hours. As soon as the abdominal pain is allayed, and the skin becomes soft, effects which almost in- variably follow the use of this anodyne, an ounce of castor oil should be given, and repeated in half ounce doses every two hours, until the bowels are freely evacuated. Should this plan fail to excite purging, enemata must be given to promote the operation of the oil. One of the best injections for this purpose is spirits of turpentine, mixed with some mucilaginous fluid. Thus: R.—01. terebinth. |j. Vitelli ovi, No. ii. Infus. sem. lin. tepid, %xvi.—M. ft. enema. When this is effected, another full dose of opium must be admi- nistered, and quietude enjoined. It is to be recollected, however, that the use of this valuable narcotic is to be restricted altogether to the advanced period of the disease, when the general and local inflammatory excitement has been in some degree broken down by sanguineous evacuations; for at an earlier period it could hardly fail proving injurious. Nothing need be apprehended from the ordinary constipating effects of opium in this disease. This article, on the contrary, is in general the best means we possess for favouring the operation of purgatives in enteritis. It lessens the extreme irritability and sensi- bility of the inflamed intestines, and thereby prevents purgatives and the usual contents of the bowels from exciting them into inordinate contraction, the principal cause perhaps of the constipation. Drs. Armstrong and-Johnson have done much towards removing the prejudices so generally entertained against the employment of opium in some of the phlegmasial affections. The former of these eminent writers states, "that his attention was drawn to this subject by observing a chasm or defect in the common modes of treating acute abdominal inflammation by the simple depletion of bleeding and purging. He had long observed, that when in affections of this kind opium was given in full doses, immediately after copious depletion, the cases terminated successfully. Within the last four years I have prescribed large doses of opium, after adequate blood-letting, in at ACUTE ENTERITIS. 227 least a hundred cases of acute and subacute inflammation in the abdomen, and always with obvious advantage." In acute peritoneal inflammation of the stomach and bowels, he makes it a rule to bleed in the first stage, until syncope approaches. As soon as the patient recovers from the faintness caused by the first bleeding, three grains of opium are administered and quietude enjoined. " The effects of opium' thus administered are to prevent a subsequent increase in the force and frequency of the pulse, and a return of abdominal pain, while it induces a tendency to quiet sleep, and a copious perspiration over the whole surface. If in three or four hours after the opium is taken, there is pain on pressure in any part of the abdomen, with a hot and dry skin, and a quick jerking pulse, I order the patient to be immediately bled in the same decisive manner."* Dr. Johnson,! in remarking on a fatal case of enteritis, observes: « Medical men now- a-days trust too exclusively to sanguineous evacuations in enteritis, and neglect certain and powerful auxiliaries which they would do well to call to their aid. If, when they have bled copiously, and as far as the patient's strength will bear, they will exhibit opium in combination with calomel, they will have the satisfaction of saving many lives. This has been my practice, and I know it to be the successful practice of one of the first hospitals of London." Schmidt- mann, one of the most experienced of the German physicians of the present day, observes, that opium deserves to be considered as among the most powerful artti-enteric remedies. He particularly recom- mends the exhibition of this narcotic, in union with calomel, and asserts that since he became acquainted with the valuable powers of this combination, he has not found it necessary to draw so much blood as before.^ In my own practice I have had repeated and * Transactions of the Associated Apothecaries and Surgeons Apothecaries, of England and Wales, vol. i, art. 3. t In his remarks on Dr. Scott's case of fatal cystitis hepatica, (Edin. Journal, April, 1825,) Dr. Johnson uses the following language, in relation to the employ- ment of opium in inflammatory affections: "We reiterate what we have often said before, that practitioners are too much afraid of opium in inflammations, especially of the abdominal viscera. Yet, after copious bleeding, there is not the smallest danger in its administration, especially if combined with calomel. But practitioners seem, in general, to have but one idea in inflammation—depletion —depletion. All other considerations are absorbed in this. The pain, and its consequences on other organs and systems, go for nothing. Bleeding and purging are the catholicons. The quantity of opium should never be considered in such cases, but only the effect. It must be given so as to subdue pain and irritation, whatever may be the magnitude of the dose."—Med. Chir. Rev., July, 1825, p. 223. X Dr. S. expresses himself in the following manner, in relation to the use of opium in this affection: " Ex quo hoc (connubium calomelis et opii) in usum verto in curanda enteri- tide non tot mihi opus est phlebotomis, quam olim, cum potens hoc remedium ignorarem. '■' Vix enteritidis curationem adgressurus essem sine opio. Et mild videtur, 228 ACUTE ENTERITIS. decisive evidence of the usefulness of opium, not only in the present, but in many other of the phlegmasial affections. When given in diseases of this kind, it ought always to be. used in large doses—from two to four grains after suitable evacuations, so as to allay the pain, and with it the general sympathetic irritations of the system. Blisters applied to the abdomen, after the local and general in- flammatory action has been in a measure subdued by venesection, are powerful auxiliaries in the treatment of enteritis. Fomentations, also, or large emollient poultices applied on the abdomen, will occa- sionally procure considerable advantage in this affection. Some writers strongly recommend tobacco injections in enteritis-—(Aber- crombie :) and they certainly tend in no small degree to diminish the momentum of the circulation, and to excite alvine evacuations, effects which are especially desirable in this affection. From the great aptitude of tobacco to produce extreme relaxation and prostration, as well as sickness of the stomach, great caution is necessary in the employment of this article, lest sudden and alarming depression be induced. An injection of this strength may be used without appre- hension of mischief from i's depressing influence :* R.—Folor. tabaci. ^ij. Aquae ferventis, gxvj.—M. The half of this will be sufficient for one enema. The ordinary internal antiphlogistic remedies, such as nitre, anti- mony, spiritus mindereri, &c, are not only useless, but almost always decidedly injurious. Digitalis may be used with advantage in the advanced periods of the disease, when the inflammation has nearly subsided, and the pulse still remains in an irritated condition—namely, quick, frequent, and sharp. The best way of giving this article is in the form of powder, of which from a quarter to half a grain may be given every hour or two, until its influence on the action of the heart is manifested in the reduction of the pulse. When the symptoms which are known to announce and accom- pany the occurrence of gangrene supervene, we should not imme- diately abandon all hopes of the patient's recovery, or cease our efforts to save him. In instances of this kind the exhibition of stimuli will occasionally speedily remove every dangerous symptom. idem, praemissis. prsmittendis, inter potentissima antienterica numerandum esse. Notum enim est, inflammationem irratione, procreari, atque fibras viventes ex- timulatas majoram exserere conatum oscillandi et se movendi: ex quo sequitur, in enteritide motum peristalticum augeri et accelerari; quod vomitas SEepe enor- mis, ut plurimum cum ea conjunctum est, inflammationem actione et motu fibra- rum partis adfectae exasperari, eandem autem quiete et vacatione a motu deliniri et compesci. Cum jam opio motus intestinorum vermicularis retardetur et hn- minuatur; ideo in enteritide ab eo princeps auxilium expectandum est: quocum experientia pulchre conspirat"—Summa Observationum Medicarum. Auctme L. J. Schmidtmann. Berlin, 1821, vol. ii. p. 110. * This remedy is recommended by Selle.—Vide Mcdkina Clinica, p. 89. Berolini, 1785. ACUTE INFLAMMATION OF THE INTESTINAL CANAL. 229 I attended a man during the present year, affected with acute ente- ritis ; on the sixth day of the disease the pain ceased, his pulse became extremely small and weak, and the hands and feet of an icy coldness, and damp, with great muscular prostration. I supposed gangrene had taken place—announced to the patient's friends his speedy and inevitable dissolution, and directed all remedial efforts to be discon- tinued, with the exception of the use of wine and water as freely as he might desire to take it. Instead of finding him dead, as I expected, on the following morning, he was so much better as to leave very little doubt of his final recovery, an event which was happily realized. Abercrombie has recorded a case of this disease, in which the import- ance of attending to this fact was strikingly illustrated.* Mild and mucilaginous diluents may be freely allowed, unless they distress the stomach, or excite sickness. During the period of convalescence, the patient should abstain en- tirely from every kind of stimulating or indigestible food. Nothing but the mildest and least irritating articles of diet should be used for several weeks after recovery. The slightest error committed in this way is apt to renew the intestinal inflammation. After an attack of enteritis, the intestines are particularly liable to become much distended with flatus, giving rise to troublesome tym- panitic distension of the abdomen. This state of the bowels may, in general, be corrected by external abdominal frictions, particularly with the flesh-brush, and by injections of infusion of mint, with assa- foetida, or turpentine. Schmidtmann recommends a decoction of the Iceland moss with colomba root, and the extract of nux-vomica, as peculiarly useful to allay the morbid sensibility of the bowels, after the inflammation has been removed. 2. Acute Mucous Enteritis. Acute inflammation of the mucous membrane of the intestinal canal may attack either the whole of this structure, from the stomach to the termination of the rectum, or only a part of it; and the symp- toms by which it is manifested, are considerably diversified, according as its superior, middle, or inferior portions, are chiefly or exclusively affected. When the inflammation is seated in the duodenum, the tongue is generally covered with a whitish fur ; the taste is bitter ; the appetite greatly diminished or entirely lost; the ivhofe surface of the body is apt to become jaundiced ;t the urine is high-coloured and bilious; there is headache : and on the external region of the duodenum, a * On Diseases of the Stomach, &c, p. 176. t Dr. James Johnson, in remarking on a case reported by Andral, jun., observes: " A curious fact has in these days of diligent investigation been pretty fairly esta- blished, namely, that irritation or inflammation in the mucous membrane of the duodenum, will sometimes produce jaundice, where no obstruction can be de- tected in the biliary duct. This fact, we think, will ultimately throw some light on the nature of yellow fever."—Med. Chir. Rev., Jan. 1828. 230 ACUTE INFLAMMATION OF THE shining fullness or puffiness may generally be perceived. The pain is not often considerable, and the bowels, though slow, may be read- ily moved by mild laxatives or enemata. More or less nausea and vomiting usually occur ; and the pulse is corded, though commonly fuller than in gastritis. (Broussais.) When the inflammation is confined to the small intestines, the tongue is coated with a white or light brown fur along the middle, with its edges and tip of a bright red colour ; the bowels are some- times loose, or are readily moved, the stools being of a mucous, or oleaginous character; and the " integuments of the abdomen hard and tender under pressure at particular points or patches." The sto- mach is generally irritable ; and a continued slight burning pain, with a sensation of weight, is felt in the umbilical region, with occasional tormina. When the inflammation is located chiefly in the mucous membrane of the colon and rectum, the disease is characterized by frequent mu- cous and bloody stools, tormina, tenesmus, and retention of the natural feces, constituting Dysentery. Symptoms.—This disease is often ushered in by a sense of lassitude, want of appetite, nausea, bad taste in the mouth, depressed pulse, slight chills alternating with flushes of heat, thirst, dry skin, transient pains in the bowels, costiveness, and occasionally diarrhoea. Some- times the disease comes on suddenly with griping, mucous and bloody stools and tenesmus, without any premonitory symptoms; and this is most apt to be the case, when it arises from causes that act immedi- ately on the mucous membrane of the intestines. In general, the fever is developed before the proper dysenteric symptoms show them- selves; sometimes more or less diarrhoea, with tormina, precedes the occurrence of febrile irritation; and occasionally mucous and bloody stools with tenesmus, are the first symptoms. From the commence- ment of the disease, throughout its whole course, little or no feces are discharged spontaneously—the stools consisting entirely of intestinal mucus, mixed with more or less blood. Tenesmus is one of the most constant and characteristic attendants on this affection ; apd the vio- lence of this painful symptom affords us a pretty accurate measure of the violence and degree of danger of the disease. There are often considerable pain and difficulty experienced in voiding urine. The tormina are extremely violent and distressing, particularly just before the urgent calls to stool are experienced; and a constant soreness is felt in the abdomen. Sometimes the stools consist almost entirely of intestinal mucus, very little or no blood being mixed up with it. In most instances, however, a considerable portion of blood is discharged with the mucus, and in some cases the evacuations consist almost wholly of blood. These dysenteric discharges usually have a very peculiar disagreeable smell, but no fetor in the beginning of the dis- ease ; but in the advanced period of violent and dangerous cases, they frequently possess a pungent and cadaverous smell; and often ac- INTESTINAL CANAL. 231 quire a corroding and sanious character. Sometimes a colliquative diarrhoea occurs, a few days previous to the fatal termination of the disease. In some instances, the heart and arteries sympathize but very little with the local mucous inflammation, the febrile phenomena being scarcely perceptible; but much more commonly, the attending fever is of a high grade. In protracted and unsubdued cases, great prostration ensues; the pulse becomes small, corded, and very fre- quent ; the countenance contracted and cadaverous; the abdomen tender and elastic, and sometimes flat; the skin harsh and shrunk ; the breath offensive, and the gums tender and swollen. An apparent amendment occasionally occurs after these dangerous symptoms have come on ; but this truce generally lasts but a short time ; for although the pulse rises and becomes better, and the tenesmus and tormina remit, the restlessness and anxiety increase ; the stools become liquid, dark, pungent, and offensive ; the countenance hippocratic ; the ex- tremities cold ; and the surface of the body moist and clammy. At first, the tongue is covered with a white fur, becoming brown, rough, and dry along the middle in the progress of the disease, with red and moist edges. In cases of a protracted, or subacute character, the edges and tip of the tongue usually become clean, smooth, and florid ; and in the chronic form of the disease, the whole surface is often smooth, clean, and red ; or red and granulated like raw flesh. The urine is always scanty and high-coloured, and sometimes of a pung- ent odour.* The hepatic and cutaneous functions are always in- active in this affection, the alvine discharges being invariably free from bile, and the skin obstinately dry during the active period of the malady. Causes.—Obstructed perspiration from cold, or vicissitude of at- mospheric temperature, is a frequent cause of mucous inflammation of the intestinal canal. A cold and moist autumn succeeding a warm and dry summer, is peculiarly favourable to the production of dysen- tery. Koino-miasmata have frequently an unequivocal agency in the production of this disease. It is doubtful, however, whether paludal exhalations are of themselves capable of exciting this affec- tion ; but their influence in modifying its general character, is fre- quently very evident in hot and marshy countries, where the disease generally exhibits a mixed character, partaking both of the nature of bilious remitting fever and of pure dysentery. In localities of this kind, it is not uncommon to find intermitting fever and dysenteric symptoms succeed each other in alternation—several instances of which I have myself observed. Dysentery seems, indeed, very often the production of the united influence of koino-miasmata and atmo- spheric vicissitudes; and hence, perhaps, the almost universal presence * Dr. Ferguson, in his account of the dysentery which prevailed during the British campaigns in Portugal and Spain, states, '■' that in the aggravated form of the disease, there appeared one never-failing symptom, which served him as a guide and diagnostic. The urine was high-coloured, even green, scanty, and pungent;" and these phenomena he regarded as the signal for the vigorous em- ployment of mercury.—Med. Chir. Trans., vol. ii. 232 ACUTE INFLAMMATION OF THE of torpor of the hepatic and cutaneous functions in this disease.* 1 he atmospheric temperature which is necessary to the production of miasmata, is sufficient also to excite the cutaneous exhalents to in- ordinate action ; whilst both the heat and the miasmata tend, at the same time to increase the biliary secretion. If, in this state of pre- disposition, a sudden reduction in the temperature of the air occurs, or if the body be exposed to the chilling effects of a humid and cool night air, the exhalents of the surface will be rendered torpid, the blood recoil from the external to the internal vessels, and the liver, in common with the other internal organs, becoming engorged with blood, will not only become further disturbed in its functions, but contribute directly to congestion in the portal vessels, and conse- quently to the rise of intestinal inflammation. There is a form of dysentery, called by some scorbutic dysentery, which appears to be the product of idio-miasmata, and atmospheric vicissitudes, or cold and humidity operating conjointly. Of this kind was the very peculiar and fatal dysentery which prevailed a few years ago at the Milbank penitentiary in England.t In this epidemic, spots or specks of a blue or livid colour appeared about the hams, and sometimes over the whole surface of the inferior extremities, and occasionally also on other parts of the body. The gums were spongy, soft, livid and much disposed to bleed; and in some, the gums ulcer- ated, the teeth became loose, and the mucous membrane of the lips and mouth black, while the breath was extremely offensive. Some of the patients passed pure blood from the bowels; others, a fluid like the washings of flesh; sometimes the stools consisted wholly of mucus and slime, streaked occasionally with blood ; and in some instances, "they contained what seemed to be lumps of flesh." Nearly all complained of a distressing and very peculiar feeling of "sinking," at the pit of the stomach. This disease was ascribed, by the com- mittee appointed to investigate its cause, to the constant and exclu- sive use of vegetable and farinaceous diet acting in conjunction with atmospheric inclemency. I think there are good grounds for believ- ing, that in addition to these causes, an atmosphere inquinated with the effluvia generated in crowded apartments, had no inconsiderable share in the production of this very peculiar affection. Although cold and dampness suddenly succeeding warm weather, may be regarded as a very common exciting cause of this disease, yet as great and sudden atmospheric changes frequently occur with- out the production of dysentery, the disease appearing extensively * " In every case of dysentery," says Dr. Johnson, " that has ever come within the range of my observation, two functions were invariably disordered from the very onset, and soon drew other derangements in their train. These were the functions of the skin and liver; or perspiration and biliary secretion. I defy any one, who has attentively regarded thisdisease at the bedside, to produce a single instance, in which these functions were carried on in a natural manner, at any period of the disease."—On the Influence of Tropical Climates, vol. ii. t An Account of the Diseases lately prevalent at the General Penitentiary. By P. M. Latham, M. D. London, 1825. INTESTINAL CANAL. 233 during some years, whilst in others it does not occur although equally variable and inclement, it would seem probable, that cold, or sudden variations of atmospheric temperature and humidity, must operate in conjunction with other general causes of an occult character, before the disease can become extensively prevalent. Among the sporadic causes of dysentery, may be mentioned the immoderate use of unripe fruit; indigestible and unwholsome food ; and irritating articles of all kinds received into or generated in the bowels. Most writers mention scybala as a frequent cause of this affection ; but the correctness of this opinion has of late been, with much justice, controverted. (J. Johnson.) Out of the very consi- derable number of cases of this disease which have come under my own observation, I do not remember more than six or seven in which scybala. were discharged. Dr. Cullen could certainly not have spoken from observation, when he declared, that "it is certain that hardened feces retained in the colon, are the cause of the griping, frequent stools and tenesmus." Post-mortem appearances.—The true pathological character of dysentery was not well understood, until within the last twenty years. Richter was of opinion that dysentery is of a rheumatic or catarrhal affection of the intestinal tube. This opinion was, indeed, formerly entertained by many pathologists; it was advocated by Akenside, StoU and Vogler. Recamier, (Rev. Medicale, Jan., 1S25,) alleges that the cause of dysentery consists in a " vitiated state of the fluids which stagnate in the alimentary canal;" i. e., the bile or the intes- tinal mucus, and the pancreatic juice. Inflammation of the mucous membrane, he says, is not primary in this affection, but secondary, the result of the irritating action of these fluids on the internal mem- brane of the intestines. Dr. Cullen considered the proximate cause of the disease to be " a preternatural constriction of the colon, occa- sioning those spasmodic efforts which are felt in severe gripings, and which efforts, propagated downwards to the rectum, occasion the frequent mucous stools and tenesmus." It does not appear that he suspected the existence of mucous inflammation as the essential pa- thological condition of this affection. Later inquiries have shown, however, that an inflamed state of the mucous membrane of the large intestines is invariably present to a greater or less extent in the disease.* In some instances, inflammation and its consequences are . found nowhere but in the colon and rectum, but frequently more or less phlogosis occupies the whole extent of the intestinal tract, from the duodenum to the rectum. But even where this is the case, the signs of inflammation and its effects are almost always conspicuous in the large intestines. When dysentery terminates fatally, in the * This, indeed, is contradicted by Recamier. He states, " when death takes place early and suddenly in dysentery, whether from the disease itself, or the supervention of another malady, we find no trace of inflammation in the intestinal canal, but only acrid fluids, which are sometimes so irritating as to cause erysi- pelas in the parts with which they come in contact."—Revue Medicale, Jan., 1825, p. 23. 234 ACUTE INFLAMMATION OF THE early or inflammatory stage, the mucous membrane of the colon and rectum presents numerous red patches, somewhat elevated above the level of the surrounding parts; and in some cases these elevated portions are covered with a number of minute vesicles—more espe- cially " in the disease as it appears in infants."* Dr. Cheyne, in his account of dissections made at the Whiteworth Hospital, Dublin, says: " the mucous membrane of the stomach and small intestines sometimes presented an inflamed appearance, which in general be- came more remarkable as the great intestines were approached." In the colon ulceration began to show itself; in the part nearest the small intestines these ulcerations were superficial; but as the bowel was traced downwards, they became deeper and more extensive. It was remarked that the last three or four inches of the rectum were sometimes almost entirely free from ulcerations. In the cases where death took place in the early stage of the disease, from the mere vio- lence of the fever, or from some other affection, the mucous mem- brane of the stomach and intestines was found more or less of a deep red or purple colour, soft and pulpy, with an uneven surface, not unfrequently rough and granulated.t In some instances considerable structural derangement of the liver occurs in the affection. Dr. Pres- ton, in his account of the dysentery which appeared in the seventy- ninth regiment at Limerick, in the year 1821, states that ''the liver was invariably deeply engaged in the disease ; it was in general con- siderably enlarged, and its whole structure apparently destroyed." That the liver is always functionally disordered in this complaint, has already been stated. In sporadic cases, however, organic derange- ment of the viscus is very rarely noticed, whilst in epidemic dysen- tery, particularly as it occurs in hot and insalubrious climates, this very frequently occurs. Prognosis.—When the discharges in the commencement consist almost entirely of blood, the disease is usually much more tractable than when they are composed chiefly of mucus, or mucus streaked with blood. Copious discharges of blood in the beginning of the disease are beneficial, perhaps, by lessening the congestion in the portal vessels. Colliquative and fetid stools, in the advanced periods of the disease, are indicative of much danger. A tympanitic state of the bowels, more especially when attended with discharges of a " muco-sanious fluid," is a highly unfavourable sign. The appear- ance of bile and the natural feces in the stools, indicates a favourable change. When the tormina, tenesmus, and tenderness in the abdo- men abate, at the same time that the skin becomes uniformly moist, we may regard the disease as tending towards convalescence; and the more certainly, if the stools assume more of a natural appear- ance. Treatment.—There are four morbid conditions present in this dis- * Abercrombie, Pathological and Practical Researches on the Diseases of the Stomach, &c, p. 226. f Medical Reports, &c, by J. Cheyne, M. D. Dublin Hospital Reports, vol. iii. p. 29. INTESTINAL CANAL. 235 ease, which point out the general indications to be pursued in its remedial management: namely, 1, inflammation of a greater or less extent of the mucous membrane of the intestinal canal; 2, general irritated vascular excitement; 3, torpor of the cutaneous exhalents; and 4, disordered functions of the liver. According to these patho- logical conditions, the principal indications are: 1, to moderate the febrile reaction of the heart and arteries, where it is excessive ; 2, to restore the regular action of the liver and skin ; and 3, to subdue the local inflammation of the bowels. In estimating the relative import- ance and urgency of these indications, it is to be observed, that tor- por of the cutaneous exhalents, and hepatic derangement, are gene- rally antecedent to the intestinal inflammation, as well as to the febrile reaction. It would seem reasonable, therefore, to conclude, that the restoration of these functions in the early or commencing stage of the disease, constitutes a primary object in the treatment of this affection, and this is indeed confirmed by experience ; for in pro- portion as we succeed in the accomplishment of this purpose, so do we equalize the circulation, lessen the determination of the blood to the bowels, and subdue at once the general febrile excitement, and the local intestinal affection. As high arterial excitement is incompatible with the regular per- formance of these functions, and tends especially to augment and sustain the local intestinal inflammation, the first step in the treat- ment of the disease is to moderate the febrile excitement, where it is excessive, by blood-letting. In many instances, however, the attend- ing fever is so moderate as not to call for direct depletion; and epi- demics occur in which the fever is of a typhoid grade, and in which the abstraction of blood is wholly inadmissible. Whenever the pulse is firm and quick, or tense and frequent, blood should be drawn. Bleeding, however, is, upon the whole, a much less useful remedy in dysentery than in many of the other phlegmasial affections. Dr. O'Brien, in his account of the dysentery in Ireland in 1821, says, " that he very much doubts if bleeding has ever succeeded by itself; or if it be capable of succeeding in this disease, as it often does in other phlegmasial affections. Blood-letting ought to be considered only in the light of a useful auxiliary, and as applicable, principally, if not solely, to the early stage of the disease." This corresponds with the observations of Broussais (Phleg. Chron., vol. ii, p. 20); and my own experience has satisfied me of its correctness in refer- ence to the dysenteries of temperate latitudes. In hot climates the disease is often very impetuous in its attack, and so highly inflam- matory, that prompt and copious bleeding affords almost the only means for checking its violence, and preventing its rapid termination in disorganization of the liver and bowels. Dr. O'Hallaran, in the dysentery which prevailed at Gibraltar in 1S24, a highly rapid and inflammatory epidemic, bled in the onset of the disease to the extent of from 30 to 64 ounces at once, so as always to induce faintness. Dr. Armstrong, too, is a strenuous advocate for decisive blood-letting in violent attacks of this disease. "Let bleeding," he says, "be once fairly introduced in the beginning of the severer modifications 236 ACUTE INFLAMMATION OF THE of dysentery, and there will be fewer fatal as well as chronic cases." Bleeding is, without doubt, a highly valuable remedy in the more inflammatory cases of this affection; but it is equally true, that in the ordinary instances of the disease, as it prevails in the temperate lati- tudes, it may very frequently be properly dispensed with. When the attending fever is of a high grade, one or two efficient bleedings in the beginning of the disease, will generally moderate the tormina and fixed abdominal pain, and favour the beneficial operation of purgatives, calomel, opium and blistering; remedies upon which our principal reliance must be placed. Purgatives, under judicious management, are among our most valuable curative means in this affection. The secretions deposited in the alimentary canal, appear to be highly acrid and irritating in dysentery, (Recamier,) and cannot fail to increase the violence of the disease, and the sufferings of the patient, when suffered to remain in the bowels. They should, therefore, from time to time be evacuated, by exhibiting the milder laxatives, throughout the whole course of the disease. Formerly, it was commonly supposed that purgatives proved serviceable chiefly by dislodging and evacuating scybalx, to the immediate irritation of which the disease was ascribed. The most active articles of this kind were accordingly employed, and repeated often to an injurious extent. I have already stated, that these hardened masses of feces are by no means very common, nor is it necessary to employ very active cathartics to remove them, when they do exist in the bowels. Dr. Johnson very correctly ob- serves, that " the search after these imaginary matters in the bowels, or rather the anxiety to dislodge them, has led to a cruel and injuri- ous system of purgation in dysentery." Our object in the employ- ment of aperients in this disease, is simply to evacuate the contents of the bowels, and the less irritation that is produced in accomplish- ing this object, the more beneficial, we may presume, will be the result. Castor oil and calomel are among our most valuable laxa- tives in this painful affection. As soon as can be, after the com- mencement of the disease, from 10 to 12 grains of calomel should be administered; and followed after the lapse of three or four hours, by an ounce of castor oil, to which 20 or 30 drops of laudanum may be advantageously added. The union of anodyne and laxative re- medies is particularly beneficial in cases attended with much pain and soreness in the abdomen. In instances of this kind, the irrita- bility of the bowels is often so great, that even the mildest laxatives frequently occasion much griping and spasmodic contraction of the intestinal tube, in consequence of which, little or no feculent dis- charges are procured by their operation. Under these circumstances, opium, so far from impeding the operation of laxatives, contributes often considerably to their aperient effects, rendering the discharges feculent, copious, and less painful. Dr. Cheyne states, that castor oil did no good in the epidemic he describes, unless it was given in con- junction with laudanum, when it always answered remarkably well. Calomel should always form a part of our laxative remedies in this disease, particularly in its early stage. This article would appear to INTESTINAL CANAL. 237 be peculiarly beneficial in the dysenteries of hot climates. Dr. John- son (on Tropical Climates) gave it in scruple doses with the happiest effect, a practice which has been pursued in the southern districts of our own country with marked benefit. In the ordinary forms of the disease, as it occurs in the temperate, and less miasmatic latitudes, however, it will seldom be necessary to resort to doses of this size, although I should apprehend no particular disadvantage from one or two such doses in the early periods of the disease. Rhubarb was at one time much employed in this affection ; but its operation is always slow and uncertain in this disease, and generally attended with very severe griping. In chronic dysentery, however, rhubarb, from the tonic powers which it possesses, may be used occasionally with con- siderable advantage. Dr. Cheyne has known half an ounce of cremor tartar, finely levigated, and given every fourth or sixth hour, to restore patients to health, " who would, he thinks, have sunk under any of the modes of treatment in use." Emetics were formerly much prescribed in this disease ; and they deserve, in fact, much more attention in the management of this affection than they appear at present to receive. Cieghorn consi- dered active emesis, produced by a combination of ipecacuanha and the cerated glass of antimony, as particularly useful in cases that begin like simple diarrhoea. We have also the testimony of Monro, Cullen, Pringle, Zimmerman and Richter, in favour of this class of remedies in dysentery ; and among the more recent writers who speak favourably of this practice, we may mention Chisholm,* Johnson, 0'Brien,t and Cheyne. I have myself had many examples of the good effects of emetics in the commencement of the disease. Pringle and Cieghorn recommend the cerated glass of antimony. The former states that he has used this remedy with success, after other articles had failed. The harshness of its operation, however, has induced physicians generally to relinquish it. Chisholm thinks the sulphate of zinc preferable to any other article of this kind. Many practi- tioners prefer ipecacuanha, and indeed this article appears to me properly entitled to preference as an emetic in this disease. It is at once mild and certain in its operation, and generally causes a per- ceptible increase of cutaneous exhalation. But its peculiar advan- tages over other emetics in this disease, arise from its tendency to allay intestinal irritation, and of increasing, rather than impairing the tone of the stomach. Emetics are especially indicated when the tongue is coated with a brown fur along its middle, and where much nausea and bilious vomiting occur in the beginning of the disease. The usefulness of this class of remedies is, however, in a great mea- sure, restricted to the early part of the disease. It is not probable that the beneficial effects of emetics in this affection depend merely on their evacuant operation. The concussion which the act of vomit- ing causes in the abdominal viscera;, excites the portal circulation, * A Manual of the Diseases of Tropical Climates. London, 1822. t Observations on the Acute and Chronic Dysentery of Ireland. Dublin, 1822. 238 ACUTE INFLAMMATION OF THE which is always more or less in an engorged state in dysentery; promotes the activity of the hepatic function; and finally strongly determines the circulation to the skin. Diaphoretics.—Sueh is the intimate relation which subsists be- tween the external and internal surfaces of the human body, that the inordinate excitement of the one is always attended with a dimi- nution of action in the other; and hence, in all diseases of the intes- tinal canal, connected either with high irritation or inflammation, the skin is dry and harsh; and hence, too, the excitation of the cuta- neous exhalents generally contributes greatly to the removal of such affections. Sudorifics have, indeed, long held a primary rank among the remedies for dysentery.* Some difference of opinion has been expressed with regard to the comparative usefulness of free sweat- ing, and of mere gentle diaphoresis in this affection. In general, a uniform moisture of the skin, will, I think, procure all the advantages which can be obtained from remedies directed to the skin. After the bowels have been adequately evacuated by mild purgatives, and the general arterial excitement moderated by venesection, where this measure is indicated by the state of the pulse, diaphoretics in con- junction with calomel, are valuable curative means. For this pur- pose, the pulvis ipecacuanhse compositus is probably the best article we possess. It may be given according to the following formula: R.—Pulv. ipec. compos, gr. xxiv. Submuriatis hydrarg. gr. vi.—M. Divide into six equal parts. S. Give one every three or four hours. A combination of opium and ipecacuanha also forms an excellent diaphoretic in this disease: from one to two grains of the latter, with one-fourth of a grain of the former, may be given every two or three hours, until diaphoresis occurs. Dr. O'Brien asserts, that a combina- tion of opium, calomel and James's powder, forms one of the most powerful anti-dysenteric remedies we possess, and Dr. Johnson con- curs with him in this observation. Much benefit may likewise be obtained from a combination of from fifteen to twenty grains of the powdered root of Asclepias tuberosa, half a grain of ipecacuanha, and a quarter of a grain of opium, given every two or three hours. About seventeen years ago, while practising in Lancaster county, of this state, I frequently employed this combination, and the result was in general decidedly beneficial. The employment of diaphoretics should be accompanied with the free use of tepid mucilaginous diluents. Calomel, with a view to its constitutional influence, is a remedy of excellent powers in this disease. It may be conveniently and advantageously given in union with diaphoretics. It,is unnecessary to cite authorities in support of the usefulness of this remedy in * Mosely asserts, that " intermittents are not cured with more certainty by the Peruvian bark, than dysentery by sudorifics." This encomium, however, is uUra rem tendere. INTESTINAL CANAL. 239 dysentery. Nearly all those "who have published their experience in relation to this affection concur in their statements respecting the good effects generally derived from a greater or less degree of mercu- rial influence in this disease. It is, indeed, seldom necessary to excite ptyalism—the slightest mercurial action being generally sufficient to obtain its curative effects in the dysenteries of the temperate latitudes. In hot and insalubrious climates, the disease frequently makes its attack with great, violence, and passes rapidly through" its course. The liver generally suffers prominently, and often becomes disor- ganized in a few days. In cases of this kind, the sooner the system is brought, under the full influence of mercury, the greater, in general, will be the chance of the patient's recovery. (Ferguson, Johnson.) Opium was, by the authority of Cullen, for a considerable period, almost wholly excluded from the list of remedies proper in dysen- tery. Sydenham, long before, had a more correct opinion concern- ing the value of this narcotic in this affection. " So important," he says, "is opium in the hands of a skilful physician, that without it his hands are, as it were, tied, and his power of doing good in dysen- tery greatly diminished." Dr. Stokes states that cases came before him, during the epidemic dysentery in Dublin, in 1818, in which the ordinary plan of treatment by diaphoretics, purgatives, and calomel, appeared to make no impression on the disease. These cases were attended with intolerance of the slightest pressure on the abdomen, agonizing pain, unceasing tenesmus, and great pyrexia, In these instances, opium in large doses, in conjunction with copious bleeding and scruple doses of calomel, often procured decided relief. " Were the same cases again placed under my care," he says, " I would not hesitate to give opium in doses of four or five grains, as it was the opium chiefly which seemed to me to arrest the progress of the in- flammation." It should be observed, however, that though a valuable remedy in this disease, opium should not be freely given in the beginning of the complaint, more especially when the febrile reaction is of a vigor- ous grade. In such cases, decisive blood-letting should be premised. But even in cases of this general phlogistic character, small doses of this narcotic, in conjunction with laxatives, generally afford considera- ble benefit. After the disease has continued for two or three days, more frequent doses may be given in the diaphoretic combinations mentioned above. As the disease advances, opiates will become more and more necessary; and in the chronic form, or where the febrile reaction is weak, they are of primary importance. From what I have witnessed in a few cases, during the present season, I am inclined to think that the sulphate of morphia, dissolved in a considerable portion of some bland mucilaginous fluid, as flaxseed tea, or decoction of the slippery elm bark, constitutes a peculiarly beneficial form for administering opium in this affection. One quar- ter of a grain in a cup of mucilaginous liquid, may be taken every four, or six, or eight hours. The nitrous acid, in conjunction with opium and camphor, is strongly recommended by Dr. Hope, of Chatham. He states that he 240 ACUTE INFLAMMATION OF THE has been in the habit of using this combination for more than twenty years, and with very marked advantage.* It may be given thus: R.—Acid, nitros. gi. Mistur. camph. §viij. Tinct. opii, gtt. 80.—M. S. Take the fourth part of this mixture every three or four hours. We are informed by Dr. Johnson, that the nitrous acid has long been used in India in this complaint, and generally with much ad- vantage.t He has himself found it very useful in chronic bowel- complaints succeeded by acute ones. In a single case of obstinate subacute dysentery, I have lately used the pyroligneous acid with marked success. The discharges, previous to the employment of this article, were very offensive—but in the course of twenty-four hours they were greatly improved both in appearance and smell; and the patient soon began to convalesce under the employment of this remedy, in conjunction with small doses of Dover's powder, calomel, and prepared chalk. Sugar of lead has also been used, in union with opium, in dysen- teric affections. Dr. Burk, of Dublin, gave it with very excellent effect, according to the following formula : R.—Acetat. plumbi, gr. iv. Tinct. opii, gii. Aq. distillat. gii.—M. S. Take from gss. to 3;i. every third or fourth hour. In this city, opium and sugar of lead have been used by a few practitioners; and, as it is alleged, with considerable advantage. (Dr. Harlan.) That this astringent may sometimes prove serviceable in the advanced periods of the disease, I have myself had convincing testimony. In general, however, all astringents, of whatever kind — but certainly, more especially vegetable astringents, are improper in the early stages of this complaint, and very often wholly useless, if not injurious, even at later periods of the disease. There may occa- sionally be found modifications of dysentery, in which this class of remedies will do much good; and of this kind was the scorbutic dysentery described by Dr. Bampfield. In general, astringents ap- pear to be much better adapted to the management of this disease, as it occurs in tropical climates—especially after the mercurial action has been gone through, and the bowels freely evacuated by laxatives. When in the advanced stage the morbid secretions continue after the inflammatory symptoms have been subdued, astringents will some- times afford considerable advantage. Under such circumstances, we may use the decoctions of cusparia, logwood, or the root of geranium maculatum or of Heucrea Americana. Abercrombie says that he has used powdered charcoal, in combination with Dover's powder, with decided benefit, in a severe case of this disease. The hydro-chloruret of lime also deserves attention as a remedy * Edinburgh Medical and Surgical Journal, 1826. t See also Observations on the Effects of Nitric Acid and Opium hi the Cure of Dysentery.—Med. and Phys. Jour., vol. iii. INTESTINAL CANAL. 241 in this affection. According to the experience of Dr. Reed of Dublin, it is capable of procuring great benefit; and it has lately been used in Germany, as I learn by a private communication, with very de- cided advantage. Dr. Reed directed a solution of ten grains of this salt, in two drachms of tincture of Colomba, diluted with four ounces of water, to be taken in half ounce doses.* The nux vomica was formerly much used in some parts of Europe, in the treatment of dysentery. Hagstrom, a Swedish physician, asserts that he found this article of very great service in this affec- tion ; and Hufeland states, that in an epidemic of this disease at Jena, in 1795, he obtained great benefits from this powerful narcotic. (Ali- bert.) From one to two and a half grains of the powdered nut should be given every two hours, after purgatives have been effectually used, and the general phlogistic excitement moderated by venesec- tion, where it is inordinate. Schmidtmann, a German physician of great experience and celebrity, observes, that he has found this article useful in allaying the tormina, and diminishing the frequency of the evacuations; but that it appeared to him to increase the violence of the tenesmus; and the same observation has been made by other writers. Opium is a much safer and better remedy, where a narcotic may be deemed proper; and to this article, accordingly, I always give a decided preference.t Tobacco also is ranked among the useful remedies in dysentery. Dr. O'Brien} employed it in the form of enemata, in the proportion of ten grains of the tobacco to six ounces of boiling water, and directed the abdomen to be fomented with an infusion of the strength of two ounces to two pounds of boiling water. When thus em- ployed, tobacco is said to moderate the action of the heart and arte- ries ; allay the intestinal spasm; promote free purgation ; relieve the tormina and tenesmus; and restore the free action of the cutaneous exhalents. Local bleeding by leeches is recommended by some, and it is most assuredly clearly indicated in this affection. It does not appear, however, from the testimony we have on this point, that the degree of advantage usually obtained from this practice, is often as great as one might reasonably expect. In infants or young children, leeching seems to be more beneficial in this disease than in adults. Neverthe- less, where there is much abdominal tenderness to pressure, and the general momentum of the circulation has been moderated by vene- section, great relief is sometimes obtained from thirty or forty leeches applied over the lower part of the abdomen. Where leeches can be procured, this mode of depletion ought, certainly, not to be neglected, especially in obstinate cases, or in such as approach to a chronic character. * Med. Chir. Rev., Jan. 1828, p. 42. t "Ab anno 1800," says Schmidtmann, "omissa nuce vomica semper unice opio ususfui, quod nunquam mea fefellit vota: fere semper adjunxi calomel."— Sum. ma Observationum Medicarum, torn, iii, p. 202. X Loco Citat. VOL. I.--16 242 ACUTE INFLAMMATION OF THE Blisters applied to the abdomen will sometimes do considerable good in cases attended wiih much tenderness and pain in the abdo- men ; but I have often known them applied without any perceptible advantage. From considerable experience with fomentations and large emollient poultices applied over the abdomen, I have been led to regard them of more service in this affection than vesicatories. In the dysenteries of children, particularly after leeching, I have derived much benefit from the application of an emollient poultice to the abdomen. - Stimulating embrocations may prove serviceable in the chronic form of the disease. For this purpose, a mixture of the oil of monarda punctata and camphorated spirits, in the proportion of an ounce of the former to two ounces of the latter, forms an excel- lent article. Where there is much abdominal tenderness, a portion of laudanum may be advantageously added to this mixture. After frictions with articles of this kind, which should be repeated three or four times daily, a broad flannel roller should be tightly worn around the body in chronic dysentery.* In chronic dysentery, balsam copaiva frequently does excellent service. Pemberton, Johnson and Cheyne speak very favourably of its use in this form of the disease. I have employed it with un- equivocal benefit. It may be given thus : R.—Bals. copaiv. §ss. Pulv. g. arab. gij. Sacch. albi 3nj. Aq. fontanae §viij. Tinct. opii gi.—M. S. Take a tablespoonful every two .hours. Dr. O'Brien, who used this article with much success in chronic dysentery, states, that the best mode of correcting its disagreeable taste, is to give it in warm milk, with which it readily mixes by means of sugar. In very protracted cases, unattended with much general febrile irritation, the spirits of turpentine occasionally proves decidedly beneficial. From 10 to 20 drops, suspended in some muci- laginous fluid, should be given every three or four hours. I have, in several cases, prescribed this article with complete success. Small doses of Dover's powder, with prepared chalk, is a very useful re- medy in the chronic form of the disease. From three to four grains of the former to ten or twelve of the latter may be given every three or four hours; and this combination may be beneficially em- ployed in conjunction with the balsam copaiva. In this state of the disease, considerable benefit has been derived from infusion of some of the vegetable astringents—particularly logwood. I have used a decoction of the root of geranium maculatum in milk, with very good effect in chronic dysentery. Abercrombie recommends a strong de- coction of cusparia with nitric acid and laudanum. Dr. J. K. Mitchell has derived signal advantage from gum water and blue mass in chronic dysentery. Several cases yielded to these remedies, after a variety of other approved modes of treatment had * Dewar on Dysentery. INTESTINAL CANAL. 243 been ineffectually employed.* In the thirteenth volume of the Amer. Jour, of Med. Sciences, Dr. J. Young has reported a case of several years standing, which, after nearly all the known remedies and modes of management for this affection had been used without permanent benefit, yielded, in a comparatively short time, under the employment of gum water, for diet and drink, together with five grains of blue mass every night, and an occasional full dose of Dover's powder. This case was under my own treatment for several months. No bene- fit, however, was obtained from my prescriptions. Anodyne and emollient enemata. are almost always highly useful in the treatment both of acute and chronic dysentery. They are par- ticularly beneficial in the dysenteric affections of infants and children. Infusion of flaxseed—of slippery elm —of althea—or a liquid prepa- ration of starch, with a full dose of laudanum, should be thrown into the rectum two or three times daily. Injections of this kind, even without the anodyne, rarely fail to relieve for a time the distressing tormina and tenesmus; and they predispose the bowels to more free evacuations from the operation of purgatives. Some speak very favourably of injections of the infusion of ipecacuanha in this affec- tion. During the whole course of the disease, mucilaginous drinks—such as solution of gum arabic, flaxseed tea, infusion of slippery elm, of althea, or very thin preparations of arrow-root, barley-water, «&c, should be freely allowed. The free employment of mucilaginous fluids is of great importance in the treatment of dysentery. From the commencement to the termination of the disease, liquids of this kind should be as copiously taken as the stomach will bear. In addi- tion to the mucilages just mentioned, we may also notice that which is obtained by decoction from the pith of sassafras. This is a very agreeable mucilage, rarely nauseating the stomach, and from informa- tion I have lately obtained, it would appear to be peculiarly beneficial in this and other forms of mucous inflammation of the bowels. In children, fluids of this kind should be repeatedly thrown into the rec- tum—a measure whkm always greatly moderates the tormenting te- nesmus. Every kind of solid food must be carefully avoided. Among the foregoing mucilaginous drinks, the infusion of slippery elm bark is, perhaps, the best. Along with its abundant mucilage, it possesses slight tonic powers—a combination of virtues which renders it par- ticularly useful in cases of a subacute or chronic character. One ounce of the bark should be infused in a pint of boiling water. Mutton suet dissolved in warm milk, is much recommended by some writers; and its effects are indeed often strikingly useful. A tablespoonful may be taken four or five times in the course of a day. Sir John Pringle speaks very favourably of yellow wax and Spanish soap melted together, as a remedy in dysentery. During convalescence from this disease, great caution should be used to avoid every kind of indigestible and irritating food. In general, some of the milder vegetable tonic astringents will contribute considerably to the speedy * Amer. Jour. Med. Sciences, No. 4. 244 CHRONIC ENTERITIS. confirmation of health. A weak infusion of the dogwood bark, or of cusparia with nitric acid, is an excellent article for this purpose. Rice, barley, oat-meal gruel, and boiled milk, are among the most suitable articles of diet after the subsidence of the disease. Sect. VII.— Of Chronic Enteritis. Chronic inflammation of the mucous membrane of the bowels, particularly of the lower portion of the small intestines and the colon, is a much more common affection than seems to be generally sup- posed. Its symptoms are often so equivocal and obscure, that the disturbances which it creates in the system are frequently ascribed to any thing else than to a phldgosed state of the internal surface of the intestinal tube. Most of the cases that are usually called marasmus, liver complaint, and dyspepsia, consist in chronic mucous inflamma- tion of the bowels. In this variety of enteritis, little or no d^inct pain is experienced in the abdomen, except when firm pressure is made on the external surface. Pain and a sense of soreness, however, are usually felt on coughing, sneezing, or any sudden motion that causes a concussion of the abdominal viscera. Connected with these symptoms, there are always considerable languor and weakness of the muscular system; the pulse is small, weak, and sharp, or corded ; the hands and feet usually cold; and slight febrile exacerbations occur towards evening, attended with flushed cheeks, and a burning sensa- tion in the palms of the hands and soles of the feet. After eating, the patient is apt to complain of more or less sharp colic pain in the bowels. Diarrhoea is, in many instances, a constant attendant; and in some cases, diarrhoea alternates with costiveness. The appetite is often very variable and capricious—being sometimes voracious, and at others entirely gone. In the advanced period of the disease, arti- cles of food taken into the stomach usually create milch uneasiness until they are evacuated by the bowels in an imperfectly digested state. When this occurs, the patient emaciates rapidly ; the abdomen in children becoming more and more tumid as the emaciation of the other parts of the body increases. The diarrhoeal discharges are usually preceded by more or less tormina; and the discharges them- selves vary much both in frequency and appearance. They are sometimes slimy, mixed with more or less feces, and small in quan- tity ; purulent and bloody ; or abundant and watery; occasionally dark or whitish ; and pieces of undigested food often pass off with them.* The skin is generally dry, and of a sallow or dingy hue; * Abercrombie states, " when the disease extends along the whole course of the colon, the feces generally come off in a liquid state, and in this case we may have the evacuations consisting sometimes of thin healthy feces, more or less combined with the morbid discharge ; and, at other times, we may find the mor- bid discharge coming off without any appearance of feculent matter. When the disease is in the small intestines, we seldom see the peculiar discharge uncom- CHRONIC ENTERITIS. 245 sleep is interrupted and not refreshing ; the tongue is almost always smooth and red round the margin, with a brown streak along the middle.* The temper is irritable, morose, or querulous, and a feeling of illness and suffering is depicted in the countenance. This form of mucous intestinal inflammation often continues for a long time without destroying life, but in many instances, the body emaciates rapidly,great weaknessensues, the mouth and faucesbecome aphthous, and the patient sinks under general hectic irritation. (Abercrombie.) Under the head of diarrhoea, this form of intestinal inflammation will be again considered ; for nearly all instances of obstinate and protracted diarrhoea consist, in reality, of chronic mucous enteritis, connected, frequently, with ulcerations. Causes.—Chronic mucous enteritis may be the consequence of the acute form of the disease. It is, however, much more frequently the result of irritation from crude and indigestible food, and other irritating substances acting directly on the internal coat of the bow- els. The protracted influence of a cold and damp atmosphere, par- ticularly when aided by unwholesome and indigestible diet, is apt to give rise to this affection. Drastic and frequently repeated purges; and, in short, every thing of an irritating character admitted into the bowels, may produce it. Post-mortem appearances.—The appearances on dissection are very various in this as in the other varieties of gastro-intestinal in- flammation. Sometimes we find a number of red patches, with fun- goid elevations in a greater or less extent of the mucous membrane; and ulcerations of different shapes and sizes almost always occur in some parts of this structure. Sometimes " there are extensive tracts of ragged ulceration alternating with fungous elevations." We sometimes find the internal surface of the colon, or the lower portion of the ileum, covered with ulcerated and indurated elevations; and frequently the area of a considerable portion of intestine is contracted, so as scarcely to admit a large-sized bougie. It is now well ascer- tained, that ulcers of the mucous membrane of the bowels frequently cicatrize ; and that such cases are not, therefore, to be regarded as altogether insusceptible of cure. Dr. Latham,! in his account of the diseases of Mil bank, relates examples of this kind; and the observa- tions of Petit, (of the Hotel Dieu,) Andral, jun., and M. Billard,have furnished us with ample and interesting evidence of the cicatrization and cure of such ulcerations. M. Troillet has also related instances in which this important process was fully demonstrated. (Jour. Gen. bined. It seems either to be small in quantity, or to come off so mixed with feces as not to be easily distinguished." * Broussais, Phleg. Chron., vol. i. t Dr. Latham, in his account of the Milbank epidemic, says: " there was, however, one appearance not unfrequently met with in our examinations, with which I was not then acquainted. This was the appearance of ulcers in the mu- cous membrane of the intestines, in the course of their progress towards repara- tion."—An account of the Disease lately prevalent at the General Penitentiary. By P. Mare Latham, M.D., London, 1825, 8vo. p. 286. 246 CHRONIC ENTERITIS. Med. and Med. Chir. Rev., July 1826, et passim.) M. Troillet, in giving an account of the dissection of a subject that had died of enteric inflammation, says: " The ulcerations were of an oval and round form, varying in diameter from six to ten lines, with fringed edges, and surrounded with a brownish circle, beyond which the mucous membrane was sound. They occupied the lower portion of the ileum. Their surfaces presented the following marks of incipient, advanced, and complete cicatrization. Those in the first state were covered with a fine pellicle, transparent even after being washed or scraped with the scalpel. It was in some degree movable on the subjacent cellular substance. In other ulcerations, where the work of regeneration was more advanced, the pellicle was thicker, slightly r opaque in some parts of its surface, and amalgamated, as it were, with the fringed edges of the sore. In those ulcers where the cica- trization was nearly completed, the pellicle had acquired the thick- ness, the consistence, and the aspect of the common mucous mem- brane. In those parts where the healing process had advanced to the greatest degree,'the fringed condition of the edges had entirely disappeared ; the surrounding circle was of a faint colour, or in some places annihilated, and the mucous membrane was completely re- generated." Treatment.—Proper dietetic regulations are indispensable, and constitute, indeed, our most valuable means for combating this affec- tion. The diet must be of the mildest kind, " and such as leaves the least feculence to pass along the intestines." Liquid farinaceous articles, such as preparations of arrow-root, oat-meal, barley, tapioca, rice and sago, constitute the best nourishment in this affection. Boiled milk, rye-meal mush, boiled rice with sugar, and occasionally a poached egg, may also be used. Animal food, in a solid form, is inadmissible. These observances are indispensable to the successful treatment of this malady. No treatment, however judicious in other respects it may be, can avail, if the patient do not rigidly and perse- veringly abstain from all kinds of solid or irritating aliment. Hav- ing given directions for the regulation of the diet, a mild laxative should be prescribed; and for this purpose, castor oil is perhaps the best article we possess. Broussais rejects, unreservedly, all kinds of laxatives in this as well as in the other varieties of enteritis. It can hardly be doubted, however, that the vitiated secretions, and acrid results of decomposition in the bowels, will be much more apt to make injurious impressions on the phlogosed mucous membrane, when suffered to accumulate, than the occasional transient stimulus of castor oil, with eight or ten drops of laudanum. My own expe- rience at least has led me to this conclusion, although I am strongly impressed with the conviction, that active purgatives, and even laxa- tives, when frequently given, are decidedly injurious. Leeches applied to the abdomen are among our most efficient means for subduing the intestinal phlogosis. They should be applied, from time to time, to an extent corresponding with the patient's strength, and activity of the pulse. Much advantage may also be obtained from the application of blisters to the abdomen; and, in a CHRONIC ENTERITIS. 247 few instances, I have known decided benefit to be derived from pus- tulation with frictions of tartar emetic ointment. Wearing a flannel bandaged tightly round the body, sometimes proves serviceable, par- ticularly after leeching, or rubefacient frictions to the belly. Among the internal remedies most useful in this affection, are small doses of Dover's powder, with or without minute portions of calomel;*" balsam copaiva in the form of an emulsion; and spirits of turpentined It may appear inconsistent to recommend balsam copaiva and spirits of turpentine in this affection, after having declared that the most unirritating diet is a sine qua non in its treatment, and that active cathartics are injurious, on account of the irritation they pro- duce in the phlogosed structure. Whatever may be the conclusions of reason on this subject, expe- rience, which is always our best instructor, teaches that both the articles in question are often decidedly beneficial in the present variety of intestinal phlogosis. There is nothing more extraordinary in this than in what is observed in the treatment of some other vari- eties of inflammation. In catarrhal ophthalmia, soothing appli- cations are undoubtedly proper; yet the application of a weak solution of lunar caustic, or of small portions of precipitate ointment, will very frequently produce an immediate amendment in the disease, whilst astringent washes seldom fail to do mischief. And we may, moreover, observe, that we apply turpentine to the inflamed skin from burns or scalds, and with great, and often immediate relief. There is a power in some articles,.besides their general stimulant effects, to produce a peculiar excitement, which, in certain states of inflammation, is particularly salutary; and this appears to be the case with the articles just mentioned in the present disease. These reme- dies should, however, be given in small doses; and they generally procure most advantage when administered in conjunction with mucilage, and small doses of opium or of extract of hyoscyamus. Dr. Grenville speaks very favourably of the employment of sulphate of copper in affections of this kind; and Dr. Abercrombie observes, that he has found this article highly useful in this disease. The dose, at first, is half a grain, combined with an equal quantity of opium, and gradually increased, if necessary, to the extent sometimes of three grains, with half a grain of opium, three times daily. Dr. Elliotson also has published cases illustrative of the good effects of this remedy in chronic inflammation of the mucous membrane of the bowels. " I had two very severe cases," he says, " in which the * R.—Pulv. ipecac, compos, gr. xxxii. i Calomel, gr. i.—M. Divide into eight equal parts. S. Take one every five or six hours. t R.—Spir. tereb.gss. Vitel. ovi. Sacch. albi. §ss. Aq. fontanae Jiij. Tinct. opii 3iss.—M. S. Take a teaspoonful three or four times daily. 248 ACUTE PERITONITIS. quantity of blood and matter evacuated, and the wretched appear- ance of the countenance, rendered the existence of great disease ot the inner surface of the intestines probable, and which would most likely have proved fatal but for this remedy. Both these men reco- vered, after having taken the medicine about six months. ' These patients took the sulphate of copper with opium, in doses of three grains three times daily.* Much benefit may be obtained in this form of enteric inflamma- tion, from the use of .the persesquinitrate of iron. From fifteen to twenty drops of it may be administered twice daily, in a small por- tion of gum water.t The sulphate of iron also, in doses of from a half to two grains, twice or thrice daily, is much recommended by Abercrombie in this affection. In some instances, decided advantage has been obtained from the use of nitrate of silver ; I have prescribed this article in union with the extract of hyoscyamus with marked benefit. Haifa grain of the nitrate, with a grain of the extract, may be given three times daily. Abercrombie mentions borax as a use- ful remedy in this affection. I have employed a decoction of the slippery elm bark, in con- junction with occasional leeching, and the use of small doses of bal- sam copaiva, with the happiest effects in several instances of this disease. Sect. VIII.—Of Acute Peritonitis. Acute inflammation of the peritoneum is frequently ushered in by a feeling of lassitude, pain in the limbs, and slight creeping chills; alternating with flushes of heat. Headache, and a sense of weight or uneasiness in the epigastrium, are equally among the first symp- toms. Acute pain is often felt in some part of the abdomen, at the very commencement of the disease. Occasionally, however, the pain does not occur until the febrile reaction is established, and in some instances it comes on suddenly, with much violence during or immediately after the first sensation of chilliness. The abdominal pain is frequently, for a time, confined to a small space, but it gene- rally soon spreads throughout the whole or a greater part of the abdominal cavity. Pain does not, however, always occur in this affection. In some instances of the most aggravated character, little or no pain, but only slight uneasiness, is felt in the abdomen—(An- dral). Sometimes the abdominal pain " moves irregularly about, remaining for a few hours in one spot, and suddenly removing to another." In all instances, pressure on the external surface of the abdomen is extremely painful. To avoid this source of suffering, the patient lies on his back, with the knees and shoulders raised, in order to take off the tension of the abdominal muscles, and the pres- * Med. Chirurg. Transactions. t The mode of preparing the persesquinitrate of iron is given in the second volume of this work, in the chapter on diarrhoea. ACUTE PERITONITIS. 249 sure of the bed-coverings.* The bowels are constipated, or moved with considerable difficulty ;t the pulse is frequent, more or less tense, contracted and sharp, and occasionally, though rarely, it is round and full. The tongue is moist, and at first covered with a thin white fur, the edges and raphe becoming sometimes red in the progress of the malady. In some instances, the stomach sympathizes strongly with the abdominal affection, the patient being harassed with nausea and vomiting in the early stage of the disease. The face is usually pale, exhibiting a peculiar sharpness of feature, and an expression of great anxiety. Constant wakefulness is very commonly present through- out the whole course of the disease, but delirium rarely occurs except towards the conclusion of fatal cases. Generally, in the course of from twenty-four to thirty-six hours, the abdomen becomes tumid, tense and elastic, from flatulent distension of the intestines, and ex- tremely tender. Respiration is oppressed and laborious in the latter period of the disease ; inspiration, especially, being short, difficult, and attended with an expression of pain in the countenance. The secretion of urine is almost invariably more or less diminished, and in some instances almost wholly suppressed. When the peritoneal coat of the bladder is the seat of inflammation, " the evacuation of the urine will almost uniformly be suspended," and much pain felt in the pelvis. The peritoneal covering of the inferior surface of the diaphragm is occasionally the principal or sole part of this membrane which is inflamed, and in this case almost constant hiccough attends —(Scoutteten.)J When peritonitis occurs in the puerperal state — constituting what is usually termed puerperal fever, the lochia almost always cease to flow; and the secretion of milk becomes arrested or greatly diminished. In cases of this kind, the general powers of the system usually sink much earlier than in cases occurring in males or in females not in the puerperal condition. Acute peritoneal inflammation is generally very rapid in its pro- gress. It seldom continues beyond the sixth or seventh day without terminating either in resolution or in death, or passing into the chronic or subacute state. It often terminates fatally as early as the third ' day; and Andral asserts that its progress is occasionally so rapid, "that only a few hours intervene between the origin of the inflam- mation and death." But when the inflammation assumes the sub- acute grade, it is frequently prolonged to the thirtieth or fortieth day before it proves fatal. Acute peritonitis is not particularly prone to terminate in gangrene.§ When this occurs, the abdominal pain sud- * " In milk fever the abdomen is soft and not painful on pressure, the rigors are slight, and the pulse seldom exceeds ninety. The countenance is natural, the breasts are swelled, hot and tender, and all these symptoms disappear in 24 or 36 hours."—Ryan's Manual of Midwifery. t " Constipation," says Dr. Johnson, " is as general a conoomitant of perito- neal inflammation, as dysenteric purging is of inflammation of the mucous mem- brane of the intestines."—Med. Chir. Rev., Sept. 1820, p. 167. X Med. Chir. Rev., June, 1824, p. 199. See also, Archives Generates, &c, for December and February, 1824. $ Abercrombie. On the Diseases of the Stomach, p. 169. 250 ACUTE PERITONITIS. denly subsides; the pulse becomes very small, frequent, and often intermitting; great muscular prostration ensues; the extremities become cold and clammy; and the countenance pale, hollow and contracted. Slight wandering delirium usually occurs at last, in cases that terminate in this way. Causes.—Acute peritonitis may be produced by mechanical inju- ries of the abdominal viscera; violent and long-continued corporeal exertions ; stricture of the colon and rectum; perforation of the sto- mach or bowels by slow ulceration, and the consequent passage of the ingesta or feces into the cavity of the abdomen; extravasation of blood, urine, or bile, into the peritoneal cavity; the action of cold on the surface of the body, causing sudden suppression of the perspira- tion; wet and cold feet; drinking cold water while the body is in a free state of perspiration; parturition; sudden suppression of the hasmorrhoidal discharge, or of the menses; metastasis of erysipelas (Abercrombie); and of rheumatism;* and it would appear a peculiar contagion, to which females are liable soon after parturition. Post-mortem appearances.—Pathological investigations have now fully established the fact that the peritoneum may be violently in- flamed without the inflammation extending to the subjacent struc- tures. That portion of this membrane which covers the stomach, intestines and other viscera, has often been found strongly inflamed, and even gangrenous, while the other structures of these organs were perfectly sound. (Broussais, Abercrombie, Armstrong.) • In some cases the peritoneum exhibits large patches of a deep purple, and occasionally even of a black colour. Strong adhesions between the intestines very frequently occur; and in some instances there is more or less adhesion formed between the intestines and the inner surface of the abdominal cavity. Scoutteten found, in several instances, subperitoneal emphysema. Sometimes these adhesions are formed without the intervention of false membrane, (Scoutteten,) but much more frequently pseudo-membranous layers form the bond of union.! * Andral, jun., has related a case of peritonitis which manifestly arose from translated rheumatism. (Repert. Generale, &c, No. 4.) Dr. James Johnson, in reference to this case, observes: u We think the most sceptical pathologist will hardly deny that there was in this case, a transference of inflammation from the joints to the peritoneum." This patient was received into La Charite whilst labouring under acute rheumatism. Several venesections were practised. After some days the rheumatism suddenly ceased, and acute pains soon came on in the abdomen. The abdominal pain speedily acquired great violence, and death took place on the third day from the disappearance of the rheumatism in the joints. On dissection, strong and extensive signs of inflammation were detected in the peritoneum. t [In the No. of the Med. Chir. Review for Oct. 1844, a new term is given for a disease, (perityphlitis,) which recalls to my mind several cases of peritoneal tumours which I have seen resulting from acute inflammation. In the case of a young man whom I attended in 1820 with the late Dr. Physick, an attack of acute peritonitis terminated in the formation of a firm tumour in the right iliac region, and a circumscribed abscess of the inferior portion of the peritoneal cavity. This was followed by an irremediable obstruction, On a post mortem examina- j ACUTE PERITONITIS. 251 White membraniform concretions are generally found also on differ- ent parts of the peritoneal surface of the stomach, liver and bowels. Effusion into the abdominal cavity, of a whitish fluid containing small flocculi of lymph, or of a reddish or yellowish fluid, almost always occurs. Blood has been found effused into the abdomen in acute peritonitis. In some cases the fluid is thick, and of a straw colour, "resembling diluted pus, with a very peculiar odour;" and in other instances, a soft, white, sebaceous matter, resembling soft butter, is found deposited in the interstices formed by the convolu- tions of the intestines. Andral found a number of small tubercles between the peritoneal and mucous membranes of the bowels, some of which were softened down, and had burst through the peritoneum. In nearly all instances, a greater or less extent of the peritoneum is found strongly injected.* The occurrence of effusion, or suppuration into the abdominal cavity, is generally announced by a diminution of the pain and ten- derness of the abdomen, attended with a sense of weight and oppres- sion in the hypogastric region ; rigors; coldness of the extremities; a soft and feeble pulse, and sometimes slight diarrhoea. Treatment.—The first and most important remedial measure in the treatment of acute peritonitis, is blood-letting. There is no inflammatory affection, in which prompt and decisive bleeding is more essential to success in its treatment, than the present one. No definite directions can be given as to the quantity of blood which it may be necessary to draw. The first bleeding ought to be carried to the extent of making a very obvious impression on the system; and it should be repeated as soon as the pain and febrile reaction rise again, if the first do not break up the violence of the disease. I tion a date-stone was detected in the appendix vermiformis, which gave origin to the inflammation of the appendix, and a prodigious effusion of coagulating lymph around it. The purulent effusion which followed traveled downwards to the cavity of the pelvis. The late Dr. Riter, of this city, was afflicted with a large and very tender tumour in the same region, which followed a circumscribed inflammation of the peritoneum, and gave him intense trouble at every return of irritation, for many years, until it finally destroyed him. In a similar case from Pike county, and in the person of a son of Mr. Hanly, the druggist, in Lombard street, the same kind of tumours were dispersed, after the subsidence of peritonitis, by a gentle ptyalism, repeated leechings and counter-irritation. I have lately seen two such cases, which terminated in abscesses of the right iliac region, discharg- ing liquid feces. In another case, which I attended with Dr. Samuel Tucker, the abscess was opened posteriorly above the crest of the ileum, from which a long lumbricoid worm eventually came out.—Mc] * Dr. Lee " has most satisfactorily proved, that all the destructive febrile affec- tions which follow parturition are invariably associated with, if not directly caused by inflammation of some of the textures of the womb or of its append- ages ; and that the type or character of the fever is probably dependent upon the particular tissue most involved; thus, that in inflammatory pyrexia the peritoneal lining is inflamed, in the congestive the muscular substance, and in the low typhoid, the veins of the uterus and ovaria."-—ilfed. Chir. Rev., 1833, p. 59. 252 ACUTE PERITONITIS. have opened a vein three times in as many hours, before a perma- nent impression was made on the disease. The period during vvhich blood-letting may be employed with a prospect of advantage in this disease, is in general limited to the first twenty-four hours from its commencement; and in many instances, a lapse of twelve hours will render this powerful remedy abortive, or even detrimental. When blood is promptly and very efficiently abstracted, soon after the in- flammation is developed, the disease is often prostrated at once, so as to yield, without much difficulty, to other suitable measures. After the violence of the local and general symptoms has been in some degree subdued by venesection, topical bleeding from the abdo- men with leeches, will in general contribute considerably to the fur- ther reduction of the peritoneal inflammation. The abstraction of blood by leeches is generally much more beneficial in peritonitis than in any other variety of abdominal inflammation, and should, indeed, always be resorted to, whenever leeches can be procured. After leeching has been employed, it will be useful to apply a large emol- lient poultice over the abdomen, which will keep up a moderate discharge of blood, for some time, from the leech-bites; and by its relaxing effect tend to promote the cutaneous exhalation from the external abdominal surface. Instead of a poultice, cloths wrung out of hot water may be kept applied to the abdomen with advantage. As soon as the abdominal pain and tenderness are somewhat moderated by the means just mentioned, a stimulating purgative should be administered, in a dose sufficiently large to excite active purging. The employment of active cathartics in this disease de- serves to be regarded as a highly important measure. In no case can they be omitted without losing the benefit of a valuable remedy. In nearly all instances of peritoneal inflammation, there is consider- able difficulty in moving the bowels; and it generally requires strong doses of the most active articles of this kind to procure free evacua- tions. The advantages which purgatives afford in this disease, are usually proportionate to the activity of their operation. This does not accord, however, with the observations of Broussais, who affirms that active purging is hurtful in peritonitis, on account of the vermi- cular contractions which it excites in the intestines, and its consequent increase of the morbid sensibility of the peritoneum. Dr. Abercrom- bie also regards active purgation as seldom necessary, and often detrimental in this disease. Independently, however, of the many authorities of the first respectability, that might be cited in favour of the use of active purgatives in this malady, I have too often had the most unequivocal evidence, in my own practice, of the decided use- fulness of purging in peritoneal inflammation, to admit, in my mind, of any doubt concerning the efficacy of this practice. Upon this point, Dr. Johnson makes the following judicious remarks: "In ab- dominal inflammation, provided the mucous tissues are not inflamed, purgatives excite the secreting vessels, not only of the whole inter- nal surface of the intestines themselves, but of the glandular organs whose secretory ducts open into the primae viae, and thus powerfully deplete locally the vascular system of the abdominal viscera. When ACUTE PERITONITIS. 253 the portion of the peritoneum reflected over the intestines is inflamed, but where the villous coat is unaffected, I hesitate not to assert from personal experience, that constipation of the bowels will, in nine cases out of ten, be a feature of the disease; and in such cases I maintain, that to excite the natural action of the mucous membrane, immediately after proper vascular depletion, is a very powerful means for checking the peritoneal inflammation; in the same way that a free expectoration from the mucous membrane of the bronchia relieves the vascular turgescence and inflammation of the parenchymatous structure, or pleural covering of the lungs."* By stimulating the mucous membrane with purgatives, we not only deplete the abdomi- nal vessels generally, but also strongly determine the circulation from the peritoneal capillaries to those of the former membrane. Of all our purgatives, castor oil in union with spirits of turpen- tine has appeared to me the most valuable in the present affection. I have, in a considerable number of instances of puerperal peritonitis, derived signal advantage from this remedy.t I have usually pre- scribed it according to this formula: R.—01. ricini §ii. Spir. terebinth. £vi.—M. S. Take the half at once, and the remainder in two hours, if purging has not commenced. * Med. Chir. Rev., September, 1820. t In one remarkable case of peritonitis, I endeavoured to procure purging by means of calomel and jalap, and infusion of senna, without success for a whole day. The disease had acquired so great a violence that I had nearly lost all hopes of the patient's recovery. Finally, I ordered a mixture of two ounces of castor oil with six drachms of spirits of turpentine, and directed the patient to take a tablespoonful every half hour. After the fourth dose, purging began, and brought off an enormous quantity of dark-coloured and extremely offensive fecal matter. The patient was greatly relieved by this evacuation, and could bear considerable abdominal pressure, which before was insupportable;—in short, all the symptoms were strikingly mitigated. Convalescence soon ensued under the use of purgatives, and a large blister to the abdomen. Dr. Hamilton administered turpentine in a few cases, but without success. Blundell and Copeland also tried it, but without any marked benefit. The pro- fession in Dublin also have ceased to employ it. All, however, who have used this remedy^ assert that it does no injury.—Med. Chir. Rev., 1832, p. 120. Dr. Dewees has recorded a case of puerperal fever which was regarded hope- less, after the antiphlogistic treatment had been fully employed. A last recourse was had to 30 drops of turpentine every hour, the application of sinapisms to the legs and an ounce of mercurial ointment rubbed on the abdomen every night, with an enema containing one drachm of laudanum. This practice was con- tinued for three successive days, and the patient recovered.—Amer. Jour. Med. Sciences, Aug. 1828. Dr. Isaac A. Johnson has published six cases, in each of which he exhibited half an ounce of turpentine with the same quantity of castor oil every hour until the bowels were freely purged, and then the medicine was continued at longer intervals. All these cases terminated favourably.—Amer. Jour. Med. Sciences. 254 ACUTE PERITONITIS. It is not always necessary, however, to resort to the use of this active purgative at once. In some instances, a full dose of calomel and jalap, or of infusion of senna, or of castor Oil, will procure ade- quate discharges; but where these articles fail to produce the desired effect, the turpentine and castor oil in union, will usually bring on copious purging. I have used with much advantage, a mixture of cremor tartar and powdered jalap in this affection. This will sel- dom fail to produce very abundant watery discharges from the bowels. There are few articles which excite so copious a discharge from the intestinal exhalents as cremor tartar; and when given in union with jalap, its operation is generally prompt and active. From twelve to fifteen grains of the jalap to forty grains of cremor tartar, may be given every hour until the bowels are freely moved. Dr. Pring strongly recommends the use of calomel in puerperal peritoni- tis, in ten grain doses, every six or eight hours. " Copious stools," he says, "quickly followed a sudden salivation, and a favourable convalescence was afterwards maintained by purgatives of the weaker sort." The application of a blister to the abdomen will often do consi- derable good, where, after decisive blood-letting and purging, some tenderness on pressure remains on the inflamed parts. Leeching, if practicable, should, however, always be premised to vesication ; but neither of these local means can be resorted to with a prospect of much benefit, until the acute character of the disease has been sub- dued by prompt and copious general depletion; The blistered sur- face should be dressed with some application capable of keeping up a free discharge; and for this purpose, the mercurial ointment is, perhaps, the most useful in the affection. Mercurial frictions have indeed, of late, been particularly recommended in the treatment of this disease. M. Velpeau has reported four cases (Rev. Medicale, Jan. 1837,) in which two drachms of mercurial ointment, applied by-frictions to the abdomen every two hours until the mouth became sore, appeared to do much good. M. Laennec also cured several cases of subacute peritonitis by mercurial frictions. As soon as the mouth became sore, the symptoms began to decline. (Rev. Medi- cale, Mai,,1824.) I have met with one case in which the superven- tion of the mercurial action appeared to exert a strong influence in arresting the further progress of the disease. This was a very acute case. Copious venesection was practised, and large doses of calomel administered with castor oil as purgatives; on the third day, the mouth was found to be sore and the breath fetid; convalescence speedily ensued. Among the internal remedies beneficial in this disease, opium with calomel deserves to be particularly mentioned. After the violence of the local and general symptoms has been broken down by energetic venesection, leeching and purging, we may, in general, resort to this combination with great advantage. I can speak with much confi- dence of the usefulness of this remedy, having, for the last ten years, employed it in this disease with unequivocal benefit in a considerable number of instances. In puerperal peritonitis especially, opium either ACUTE PERITONITIS. 255 alone or in combination with calomel, is often peculiarly serviceable. " In puerperal fever," says Dr. Armstrong," in which the peritoneum chiefly sustains the intensity of the inflammation, opium may be given with considerable advantage, particularly when the local pain and constitutional irritation are excessive; though in that stage of excitement, it must not for a moment be forgotten, that bleeding and purging are the principal measures. When the stage of collapse approaches, opium may, perhaps, be accounted the primary measure, since the allaying of irritation is then the principal object. When- ever opium is administered in any species of abdominal inflamma- tion, the dose should be large ; for a small dose often stimulates, whereas a large one is a direct sedative." This narcotic may be very usefully administered in this affection at the same time that cathartics are employed; for opium in large doses, whilst it allays the pain and general irritation, often manifestly promotes the opera- tion of purgatives in peritoneal inflammation. I have usually pre- scribed this article in combination with calomel, in the proportion of two grains of the former to three of the latter every three or four hours. Antimony and nitre are seldom admissible in this disease, on account of the great gastric irritability which usually prevails; Digitalis has been recommended as a useful article in this affection. When the pulse remains irritated and sharp, after the disease has been in a great degree subdued, digitalis in small, but frequent doses, may be advantageously used. One grain should be given every two or three hours, until the frequency and tension of the pulse are sufficiently moderated. Most practitioners employ this remedy in much larger doses than the one just mentioned; but I have generally found the action of the pulse more speedily moderated when given frequently and in small portions, than in larger ones at longer intervals. When a state of collapse, ensues after the inflammation has been overcome by the means already mentioned—an event which occa- sionally occurs in puerperal peritonitis—it must be counteracted by the employment of stimulants. Wine, the carbonate of ammonia, opium and camphor, and Dover's powder with quinine, are the best articles for this purpose. " There is a period in some cases of ab- dominal inflammation where the disease is just subdued, but where there is a kind of balance between recovery and gangrene. The pain will vanish; the pulse become weak; the vital powers appear to sink, and a coldness overspread the body. The symptoms are too often indicative of mortification; but every experienced practi- tioner must have occasionally witnessed cases of recovery even from this alarming state. Here we must give wine; for, if gangrene have commenced, no harm can ensue from the remedy; and if it have not commenced, the wine may happen to give a salutary stimulus to the nervous and vascular systems, when stagnation of the vital fluids is on the point of taking place, and where further evacuations would be instant death."—(Johnson.) The nourishment throughout the whole course of the disease should be of the mildest and weakest kind. A little thin barley or 256 CHRONIC PERITONITIS. rice-water, may serve at once for food and drink. The greatest care must also betaken to guard the patient against taking cold during the period of convalescence; as a renewal of the disease, in a subacute form, is extremely apt to occur from this and other exciting causes. Sect. IX.— Of Chronic Peritonitis. The approach of chronic inflammation of the peritoneum, when not the sequel of the acute form of the disease, is so gradual and in- sidious, that it seldom becomes the object of medical attention until incurable structural changes have taken place, or effusion into the cavity of the abdomen. It is only by attending to the passage of the acute into the chronic form, that we are enabled to give an account of the early symptoms of the latter. When the peritoneum becomes affected with the chronic inflammation, more or less uneasiness and tenderness are experienced in the abdomen, and when pressure is made externally, or the patient coughs, sneezes, or performs any sudden motion by which a concussion of the body is produced, a feeling of soreness is felt about the umbilical region. In many instances, there is slight pain in some part of the abdomen, which may be either con- tinuous or occasional. In no instance, however, is the abdominal pain severe, for serous membranes, in a state of chronic inflammation, never give rise to acute pain ; and many cases are recorded in which this structure was found completely disorganized from chronic inflam- mation, without the patient having complained of any pain whatever. The abdomen generally becomes fuller, and in some instances elastic, or more or less tympanitic. Frequently, a sense of tightness and pricking soreness is felt across the lower part of the abdomen, after fatigue from bodily exertion. " There is no tension of the skin of the abdomen as in the acute species; on the contrary,the skin and abdomi- nal muscles often sit loosely upon the peritoneum, which gives a sen- sation to the touch, as of a tight bandage underneath, over which the skin and muscles may be felt, as it were, to slide. The patient always complains more of tightness than of pain; and as the tight- ness is much increased by any congestion in the bowels, the relief which he experiences from evacuating their contents leads him to attribute his sensations to an habitual costiveness."* On feeling the external surface of the abdomen, we sometimes find deep-seated spots of induration which are more or less tender to the touch. (Abercrombie.) In some instances, the patient experiences a sensation as if a ball were rolling about the abdomen. Broussais ascribes this sensation to the adhesion between the different convolu- tions of the intestines into a round and movable mass. Such adhe- sions between the coils of the intestines may be suspected, says Arm- strong, " by a lobulated or irregular feel of the bowels under the hand when passed over the abdominal integuments." The bowels in this affection are generally torpid. The pulse is often not perceptibly * Pemberton on the Viscera. CHRONIC PERITONITIS. 257 affected ; except in the advanced periods of the disease, and towards evening in the early stage, when it usually becomes jerky or some- what accelerated, quick, and contracted. The appetite is generally sufficiently strong, nor is the function of digestion particularly dis- ordered, but in some instances vomiting occasionally occurs. The face and whole surface of the body are generally pale, with an ex- pression of ill health and langour in the countenance. Slight febrile exacerbations towards evening, with more or less oppressed respira- tion and cough when the patient lies horizontally on the back, and the appearance of oedema of the feet with paucity of urine, are pretty certain indications that effusion is taking place in the abdomen. The affection is not unfrequently connected with disease of the lungs. Chronic peritoneal inflammation varies greatly with regard to its duration. It sometimes terminates in fatal disorganization and effu- sion within a few months ; and cases occur which continue in a very slow and insidious way for many months, and even for several years, before the system is worn down by the general irritation it ultimately causes. Whether protracted or short in its course, this affection of the peritoneum always terminates in more or less effusion, or suppu- rative secretion in the cavity of the abdomen. In truth, ascites is, in the majority of cases, dependent on a low degree of inflammatory irritation of the peritoneum. Causes.—Chro7iic is frequently a sequel to acute peritonitis. It sometimes occurs as the consequence of acute mucous inflammation of the intestinal canal—the inflammation passing from the former membrane to the peritoneal covering of the bowels. This is, indeed, no uncommon occurrence. I have met with two instances of sub- acute peritonitis, which came on in consequence of dysentery; and one other remarkable case which supervened on acute mucous in- flammation of the bowels, brought on by irritating ingesta. Dr. Hodge of this city has given an account of a well-marked case of this kind, which was evidently produced by dysenteric inflammation.* Long- continued torpor and congestion of the portal system from hepatic tor- por or protracted constipation, are probably sometimes the cause of this affection. It may also be the consequence of acute or chronic inflam- mation of the solid viscera of the abdomen—particularly of the spleen and liver. Blows or injuries inflicted on the abdomen; difficult par- turition ; suppression of perspiration, and of hemorrhoidal discharge; metastasis of erysipelas; cold, &c, will sometimes give rise to this affection. Post-mortem appearances. — More or less fluid is invariably found effused into the cavity of the abdomen in those who die of this affec- tion. This fluid is commonly of a whitish or whey-like colour; some- times it is limpid and yellow ; and occasionally it is found of a red- dish appearance, with small flocculi of false membrane floating in it. Occasionally, though rarely, the extravasated fluid is mixed with a .considerable portion of blood ; and instances occur in which it ap- pears to consist of pure blood. (Scoutteten.) I have met with a case * American Journal of Medical Science, &c, April, 1829. VOL. I.—17 258 CnRONIC PERITONITIS. of this latter kind. The intestines are often glued together in differ- ent parts by the intervention of false membranous matter ; sometimes sacs are formed by these membraniform exudations, and the intes- tines, containing purulent matter or other fluids of various appear- ances. Occasionally the intestines are found agglutinated into one mass, " and partly covered with thickened and adherent momentum." (Broussais ) Thickening of the peritoneum is a very common post-mortem phenomenon in this affection. In some instances, this membrane, though thickened and otherwise disorganized, is but little injected or red; in other cases, it is found reddish and highly injected. Very frequently the surface of the peritoneum is covered with innumerable small white granulations of a tubercular character.* Bayle states, that in a subject he examined, where these tubercular depositions were very abundant, he could easily scrape them off with a scalpel; and where this was done, the peritoneum underneath appeared per- fectly sound. In some instances, the peritoneum is considerably thickened by granular depositions between its two layers. (Gasc,t Broussais, Abercrombie,:): Pemberton.) The mesenteric glands are usually enlarged and indurated. Treatment.—Chronic peritonitis might, perhaps, be generally removed, if it could be subjected to remedial treatment during its incipient or early period. Such, however, are the obscurity and un- certainty of its early phenomena, that it rarely becomes an object of medical attention until it has proceeded to an extent which renders the most judicious treatment almost invariably abortive. Broussais, indeed, for a considerable time regarded this affection as wholly be- yond the reach of remedial management. Subsequent experience, however, convinced him that if proper remedies are applied during the first twenty or thirty days of the disease, it may sometimes be effectually subdued, and he thinks it possible that it may yield even at a much later period Of its course. This writer accounts for the great difficulty of curing this form of peritoneal inflammation, by referring it to the impossibility of producing the absorption of the tubercular matter which is so constantly deposited between the layers of the peritoneum, and which therefore keeps up a continued irri- tation in this membrane. External irritating and depleting applica- tions to the abdomen, constitute our most efficient means for com- bating this affection. Leeching is decidedly indicated, and often, no doubt, contributes considerably to the removal of the disease, where disorganization or effusion has not yet occurred. After local deple- * " It is always difficult, and frequently impossible," says Dr. Armstrong, " to predicate that tubercles exist on the serous membrane of the abdomen. But when the skin assumes a delicate hue—when the conjunctiva is blanched—when the expression of the face is more softened and pensive than natural, and espe- cially when the patient has any cough, a presumption of their existence might be- excited." t Dictionnaire des Sciences Medicales, vol. xl. X Edinburgh Medical and Surgical Journal, No. Ixiii. CHRONIC PERITONITIS. 259 tion, a large blister should be .applied over the abdomen, and kept discharging by dressing it with mercurial ointment. From several instances which have lately come under my notice, I am inclined to regard pustulation, by means of tartar emetic ointment, more effica- cious than blistering. We may also use stimulating frictions, followed by emollient applications to the abdomen, with a prospect of advan- tage ; more especially where the general system is in too irritable a state to admit the more irritating applications just mentioned. The application of moxa to the abdomen has never, I believe, been recom- mended in the treatment of this affection. From its known power- ful influence in subduing deep-seated inflammations, it is not im- probable that considerable and prompt benefit might be derived from this application in the present affection. The warm bath has also been recommended as a useful auxiliary in the treatment of this dis- ease. Within the last few years, frictions with mercurial ointment have been used with success in this affection, by Velpeau and Laen- nec ; and from the accounts which they have published, this remedy would seem to be entitled to very great consideration. The latter writer has reported seven cases of chronic ancl subacute peritonitis which yielded to mercurial frictions. Two drachms of the ointment should be rubbed in every two hours, until the gums become slightly affected. Since the publication of the first edition of this work, I have witnessed the good effects of this practice in a well-marked case of this variety of peritonitis. The disease had continued several months before I prescribed for the patient. The abdomen was en- larged, very tense, and extremely tender to the touch. A course of mercurial frictions over the abdomen, together with one of the fol- lowing pills* at night, had the effect of gradually subduing the dis- ease, and restoring the patient's health. Diuretics also are strongly recommended in the treatment of this disease, but they can be re- garded only as auxiliary to the more direct and efficient applications already mentioned. Broussais advises the use of diuretic articles in the way of frictions on the abdomen. The tincture of cantharides, or of squills, may answer for this purpose. If any advantage is to be derived from this class of remedies, however, it will probably be belter to exhibit them by the mouth, whilst other more efficacious applications are made to the abdomen. Dr. James Johnson recom- mends the following combination as a particularly powerful and useful diuretic, in the present, as well as in other affections: R.—Acidi tartarici Qi. Soda; carboni, gr. xxiv. Infus. digitalis, fl. ^ss. Spir. astheris nitrici, fl. 3i. Tinct. scillse, M. iv. Aq. menthse j|ij.—M. ft. This dose to be taken twice or thrice daily. Mild laxatives must from time to time be used, so as to obviate * Ii.—Massae. hydrarg. gr. xxx. G. aloes, gr. x. Tart, antimonii, gr. i.—M. Divide into ten pills. 260 ACUTE HEPATITIS. costiveness and consequent irritation from this source. Castor oil, or the acetate of potash, and cremor tartar, will commonly answer well for this purpose. Although active, purgatives are not among the means generally recommended in this disease, 1 have in a few instances known decided benefit to result from the employment of the following mixture. Ii.—Crem. tartar giss. Pulv. scillae gi. Pulv. sulphat. potass, gij. Tart. Antimonii, gr. ij.—M. ft. S. Take gss. three or four times daily. This combination produces copious watery discharges from the bowels, and stimulates the kidneys to increased action. To allay the general irritation which is apt to occur in this disease, we may give small doses of Dover's powder, or full doses of extract of hyoscyamus, or of conium maculatum. From the diaphoretic tendency of the first of these articles, it deserves, I think, a preference in this affection. It is of great importance' in the management of this disease, to restrict the patient to the weakest and mildest articles of nourishment. Dr. Johnson observes, in reference to the possibility of procuring the absorption of the tubercular matter deposited in the peritoneum in this disease: "There can belittle doubt that the ab- sorbents might be made to act upon many extraneous and morbid growths in the human body, by rigid abstinence alone, if patients had fortitude to persevere in the measure. For our own parts, we 'should place more confidence in this than in any other remedy; and practitioners should at all times bear in mind, that without strict abstemiousness, there is little hope of a cure in chronic peritonitis." —(Med. Chir. Rev., Sept., 1820.) May we not expect some advan- tage from iodine, in the form of frictions on the abdomen, in this affection? It appears to me worthy of trial. Sect. X. — Of Acute Hepatitis. Although not a very frequent disease in the temperate and colder latitudes, hepatitis is one of the most common maladies engendered by the influence of an intertropical or hot climate. The acute form of this disease often makes its attack suddenly, and with great vehe- mence, particularly in those parts where it prevails endemically; as along the sandy coast of Coromandel, and the marshy districts of Bengal. When the invasion occurs thus suddenly and violently, the patient is seized, without scarcely any previous symptoms of indis- position, with pain in the right hypochondrium, accompanied with a sensation of tightness across the abdomen ; difficult respiration ; and an inability to continue in the recumbent position ; the patient feeling easiest when in a sitting posture with the body inclined forwards. This mode of attack is frequently observed in the intertropical regions. In the temperate latitudes it usually comes on in a more gradual and less impetuous manner. The patient complains of a feeling of tight- ACUTE HEPATITIS. 261 ness in the right hypochondrium and epigastric region, with slight incipient febrile symptoms, for a considerable time before the true character of the disease becomes obvious. The pain attending acute inflammation of the liver, is apt to extend itself from parts remote from this organ, more especially to the breast and to the clavicle and shoulder of the right, and sometimes the left side. In some in- stances these sympathetic pains are even more severe than those experienced in the liver itself. Mr. Annesley observes, that when the internal structure of the liver is the seat of the inflammation, the pain is generally heavy and aching; but when the surfaces or the ligaments become affected, it is usually acute, tensive and pungent. Pressure on the right hypochondrium always greatly aggravates the pain in that part; and a similar effect is almost invariably produced by an attempt to lie on the left side; although in some instances the reverse obtains, the patient feeling 77/05/ ease when recumbent on the left side. A dry and troublesome cough, with more or less difficulty of breathing, are common attendants on this disease. When these symptoms are connected with pain in the thorax, the disease may be readily mistaken for pneumonia. Nausea and bilious vomiting frequently occur in acute hepatitis, and in general, the severer these symptoms are, the less cough and difficulty of respiration'will be experienced by the patient. In many instances, there is a distressing "feeling of anxiety at the epigastrium and prascordia, accompanied with frequent deep sighing, particularly when pressure is made simul- taneously on the right hypochondrium, and under the right shoulder- blade." A more or less jaundiced hue of the white of the eyes, and skin about the breast, face and neck, is one of the most constant phenomena of this disease.—(Louis.)* The urine, also, is invariably highly imbued with bile, exhibiting a deep yellowish-brown colour. The thirst is usually very urgent, and the skin hot and dry. The pulse is generally full, active and firm; but in some instances it is small, tense and quick: and this is said to be the case when the concave surface of the liver is the seat of the inflammation, and the peritoneal surface of the stomach or colon participates in the inflam- mation. The tongue is coated with a white or thick yellowish fur, and the taste is often bitter; or, " it is smooth and glossy, marked by fissures, and lobulated." (Annesley.) In general, the bowels are cOstive ; yet, in hot climates, diarrhoea often attends from the beginning of the malady. (Chisholm.) Cases of this kind generally commence like dysentery. The patient is seized with violent griping, followed soon by small watery or slimy discharges from the bowels, accompanied with soreness at the pit of the stomach, or of the right side. If pressure is made on the right hypochondrium, the patient shrinks from the touch ; yet the pain in this part is seldom violent. " The degree of violence of the bowel affection," says Dr. Johnson, " will very generally indicate the degree * Mr. Annesley states, that jaundice is not a frequent concomitant of hepatitis in India, unless the ducts or gall-bladder become involved in the disease, or when it supervenes to biliary calculi, or other obstructions of the ducts. 262 ACUTE HEPATITIS. of rapidity and danger of the hepatic inflammation. A scalding sen- sation in making urine almost always occurs; and the brain often sympathizes strongly with the liver in this affection, giving rise to more or less mental disturbance." Acute hepatitis rarely continues beyond the sixth or seventh day, without tending either to resolution or suppuration. When the latter has taken place, the pain becomes moderated; the patient experi- ences a sense of weight and throbbing in the region of the liver, with irregular rigors; more or less profuse night sweats; a sense of sink- ing, with anxiety and oppression in the praecordia; a clammy skin; and a sense of formication. In some cases, " nearly the whole of the right lobe becomes one enormous abscess." Sometimes adhesions take place between the parts surrounding the hepatic abscess and the internal surface of the abdomen; and when this occurs, and the abscess points outwards, the pus may be discharged by puncture or incision, and the patient often cured. When the abscess is about pointing externally, the general fullness, distension and pain in the region of the liver and epigastrium, which occur before the suppu- rative process commences, are at first somewhat increased; but as the suppuration goes on, and the matter proceeds outwardly, a soft and more or less circumscribed tumour makes its appearance, whilst the general fullness and tenderness in the right hypochondrium in a great measure subside. " When the abscess advances beneath the false ribs, or near the epigastric region, it is generally sufficiently per- ceptible ; but when it points higher up, or more posteriorly, so as to come beneath the ribs, then the bulging out of the hypochondrium is merely marked with fullness of the intercostal spaces, and pain and soreness limited almost entirely to one spot. In a great majority of hepatic abscesses, the direction is to the exterior and superior surface of the liver, and hence the communication so frequent with the dia- phragm and lungs when they fail in pointing more externally." (An- nesley.) Sometimes the liver forms adhesions with the colon, or some other portion of the intestinal canal, and the abscess bursting into it, the pus is discharged by stool. Dr. Saunders thinks it probable, that the matter formed in the substance of the liver, may sometimes pass into the bowels through the biliary ducts. When adhesions form between the liver and diaphragm, the abscess may burst into the cavity of the thorax, or into the pulmonary cells, in which latter case it is often brought up copiously by expectoration. Dr. Wilson* ob- serves, that there is perhaps no instance of recovery after this accident; an observation, however, which has been abundantly contradicted by the experience of others. I have seen an instance in which an enor- mous quantity of thin reddish pus was discharged from an hepatic abscess through the lungs, followed by a perfect recovery of the patient's health. Annesley mentions cases of this kind ;t and Schmidt- mann J relates two instances of a similar character and successful ter- * On Febrile Diseases. t Loco citat. X Summa Observationum Medicarum, vol. ii. ACUTE HEPATITIS. 263 mination.* Purulent expectoration sometimes attends hepatitis, from the inflammation extending to the mucous membrane of the bron- chial tubes, or to the substance of the lungs, without any direct com- munication between the abscess in the liver and the cavity of the thorax. Cases occur, in which the hepatic abscess bursts in the cavity of the abdomen; these are almost necessarily fatal. It has been doubted whether an abscess containing laudable pus can be formed in the parenchymatous structure of the liver. Louis states, that by far the greater number of abscesses which occur in the proper substance of the liver do not contain genuine pus, but a fluid less homogeneous, containing small flakes of blood of a darkish gray colour, or like the washings of flesh. In 430 dissections, he found but five instances of purulent abscess in the substance of the liver, and not one in its coverings. When genuine pus is formed in hepa- titis, the abscess probably occurs in the cellular membrane, between the peritoneal covering and the glandular structure of the liver.t Gangrene also, though very rarely, occurs in hepatic inflamma- tion. (Bichat.) Annesley, however, seems to doubt whether this mode of termination ever takes place in hepatitis. He states that he never met with an instance of this kind, although his opportunities for observation were very ample. In some instances, the disease terminates in a softening of the struc- ture of the liver. Annesley sometimes found the surface of this viscus " marked with red, brown, brick-coloured, greenish-brown, and even with almost black spots and streaks, while the internal structure was inflamed, congested with blood, much tumefied, and softer than na- tural." Abercrombie found the parenchyma of the liver soft, broken down, and nearly of a black colour.f It is supposed by Dr. Saunders,§ that in the acute variety of this disease, the capillaries of the hepatic artery are exclusively impli- cated in the inflammation; and that in the chronic form the inflam- mation exists in the extreme branches of the vena portse. The same opinion is expressed by Professor Puchelt;|| and Winslow ascribes , both varieties to an inflamed state of the vena portae. There is cer- tainly no good reason why the capillaries of the vena portae may not become the seat of inflammation ; and when we take into con- sideration the peculiarity of the hepatic circulation, the opinion of Dr. Saunders is not without considerable plausibility. Diagnosis.—Pain in the right clavicle and shoulder has generally ' * Louis asserts, that abscesses in the liver are incurable; for in all his exami- nations he never found a single instance of cicatrization in the liver. Dr. John- son remarks, upon this assertion, " that those who have practised in India know that abscesses of the liver will heal occasionally, whether they are opened exter- nally, or make their way into the intestines."—Med. Chir. Revj^ January, 1827. t Memoir on Abscesses of the Liver. By M. Louis.—Repertoire Med., No. ii.; 1826. X Pathological and Practical Researches, &c. &c. Edinburgh. 1828. $ On the Liver. II Ueber das Venen System, &c. Leipsic, 1815. 264 ACUTE HEPATITIS. been regarded as one of the most characteristic phenomena of hepa- titis. This symptom, however, is much less common than is gene- rally supposed. M. Louis* doubts whether it is really indicative of hepatic inflammation, and thinks it arises usually from some affection of the lungs or pleura. Upon this subject Mr. Annesley observes: <'■ The pain sometimes complained of at the top of the right shoulder, and so improperly stated as being one of the chief signs of hepatitis, is, when present, certainly characteristic of the disease in the right lobe; but unfortunately this symptom is only occasionally present; and the inexperienced practitioner, who has been taught to look to this as a distinctive mark of the disease, infers, when it is not ob- served, that the liver is sound."! Hepatitis may be distinguished from pneumonic inflammation, by the following diagnostic circumstances. In pleuritis, the cough and oppression in the chest are much severer than in hepatitis. In the latter affection, the patient rests easiest when lying on the affected side; in the former, the reverse obtains. In hepatitis, pressure on the right hypochondrium greatly aggravates the pain, whilst pres- sure on the intercostal spaces produces little or no increase of suffer- ing; in pleuritis, the former does not, but the latter does increase the pain. When the substance of the lungs is inflamed, the difficulty of breathing and the pain are aggravated by lying on the sound side, as in hepatitis; but in the former affection, respiration is performed chiefly by the action of the abdominal muscles and the diaphragm; whereas, in the latter, (hepatitis,) breathing is effected almost entirely by the action of the intercostal muscles—the chest being sensibly dilated and collapsed by the act of respiration, whilst the abdominal muscles are quiescent. The pneumonic symptoms are always most conspicuous when the convex surface of the liver is inflamed. The diagnosis between hepatitis and inflammation of the stomach is rarely attended with any difficulty. The latter affection is almost invariably attended with a very contracted and weak pulse, whilst in the former it is generally moderately full and hard. In gastritis, great muscular prostration usually attends from the commencement of the disease, and every thing taken into the stomach is commonly almost immediately rejected; in hepatitis, the strength is at first not much impaired, and although frequent vomiting may occur, it is not so readily excited by ingesta as in gastritis. In the former, pressure on the right hypochondrium—in the latter, pressure of the epigastric region, causes most pain. From the pain produced by the passage of biliary concretions through the gall-ducts, or by spasm of these passages, hepatitis is distinguished by the absence of fever in the former, the pulse rarely rising above 90 beats in a minute, and the heat of the skin being but little or not at all raised above the healthy standard. In Spasm, or irritation by biliary concretions of the gall- ducts, the pain often intermits for a time; in hepatitis, it is continu- * Repertoire Med., No. ii., 1826. t Researches into the Causes, Nature and Treatment of the Diseases of India, &c. By James Annesley, Esq. ACUTE HEPATITIS. 265 ous. In the former affection, the easiest posture is when the body is bent forward on the pelvis; in hepatitis, the patient leans a little to the right side, with the knees slightly drawn up. When the inflam- mation is confined to the peritoneal covering of the liver, there is always more pain and fever than when the glandular structure of this organ is the seat of the disease. (Abercrombie.) Causes.— Dr. Saunders and others describe the frequent occurrence of hepatitis in hot climates, to the prevalence of a peculiar miasm in these regions. There can, indeed, exist but little doubt, that koino- miasmata often contribute materially to the production of this dis- ease ; but their agency is probably rather predisposing than exciting, in relation to this affection. Miasmata unquestionably possess an especial power to derange the biliary functions; and it may be rea- sonably presumed, that where, from the general prevalence of this cause, in conjunction with high atmospheric heat, the liver is in an habitual state of morbid excitation or functional derangement; every adventitious exciting cause—such as the sudden influence of a cool and damp night air ; errors in diet, and consequent gastric derange- ment; the intemperate use of spirituous liquors, &c, would be pecu- liarly apt to develop inflammation in the biliary organs. Dr. James Johnson has advanced some novel and very plausible sentiments in relation to the etiology of this disease. He observes, that " between the extreme vessels of the vena portarum in the liver, and those on the surface of the body—in other words, between the biliary secre- tion and the perspiration, there exists one of the strongest sympathies in the humau frame; and that, whatever increases or decreases the action of the cutaneous exhalents, increases or decreases also the secretion of bile in the liver. Knowing, therefore, as we do, how uniformly high atmospheric temperature excites excessive perspira- tion, we cannot be at a loss to account for the frequency of hepatitis in hot climates. The excessive and continued perspiration occasions a loss of tone in the extreme vessels of the surface; and this loss of tone in the capillaries of the skin, is accompanied by a corresponding loss of tone in the secretory vessels of the liver. As, however, the perspiratory vessels, from their excessive and long-continued action, become debilitated and extremely sensible to the slightest degree of cold, so when the temperature of the atmosphere is suddenly reduced, as is generally the case in hot climates during the night, when the dew falls, the extreme vessels of the surface are instantly struck tor- pid, which, in consequence of the sympathy just mentioned, is imme- diately followed by a similar torpor of the secretory vessels of the liver. The perspiration and biliary secretion being, therefore, thus simultaneously arrested, and the passage of the blood through the liver obstructed, a commotion is raised, which, as there already exists a congestion in the portal circle, falls mainly upon that system, and gives rise to inflammation." That there exists a strong sympathy between the liver and the skin, is strikingly illustrated by the fact, that in chronic hepatic inflammation, or in torpor, or scirrhus of this organ, the skin is always dry and harsh—it being nearly impossible 266 ACUTE HEPATITIS. in these affections to excite a perceptible general exhalation from the surface. . . It appears to me, nevertheless, that the influence of malaria is too much overlooked in this sympathetic doctrine. High and continued atmospheric heat is so universally attended with the extrication of miasmata, that it would seem extremely difficult to say how much of the previous hepatic excitation, and consequent atony, is to be ascribed to the one or the other of these causes. That a very con- siderable share of the effect in question is to be placed to the account of malaria, seems to be demonstrated by the fact, that bilious and hepatic affections are far from being common on board of ships cruis- ing in tropical seas, and where the materials for miasmatic exhala- tions are absent; although the influence of atmospheric heat is con- stant and great. Besides the exciting causes just mentioned, there are many others of a less general character, capable of giving rise to this affection. Violent and fatiguing exercise; contusions of the right hypochon- drium ; metastasis of gout* and rheumatism; wounds and injuries of the cranium;! atmospheric vicissitudes; a draught of cold water while the body is in a state of free perspiration; irritation from biliary concretions in the gall-ducts; suppression of haemorrhoids; violent rage ; terror ;J and mental despondency,§ &c, may all give rise to acute inflammation of the liver. Hepatitis may be excited in children by the irritation of dentition.|| Treatment.—In this disease, as in other inflammatory affections, the abstraction of blood is a primary remedy. There are two rea- sons for resorting to decisive blood-letting in the commencement of this affection—namely, the necessity of promptly lessening the gene- ral momentum of the circulation, as well as the congestion in the liver and portal vessels ; and the importance of subduing the general phlogistic condition as early as practicable, in order to favour the effects of mercurial remedies, upon the prompt influence of which much of our reliance must be placed. (Johnson.) As soon as blood * Quantis implicetur, says Schmidtmann, periculis hepatitis ex podagra retro- pulsa subnata lugubri illustris Augusti Gottl. Richter, praeceptoris mei summe colendi interitu probatur; qui quippe ex podagra hepar petente et inflammante, annum agens septuagesimum, post paucos ab invasione dies occubuit.—Observ. Medicar., torn. ii. p. 231. t Louis doubts this:—The rise, however, of hepatic inflammation and ab- scesses from this cause, is well established by the testimony of many observers. See the Memoirs of M. Bertrandi and M. Andouille, in the Memoires de l'Acad. Roy. de Chirurg., torn. iii. p. 439. X Schmidtmann mentions an instance of hepatitis caused by"terror: "Jam memoravi me deprehendisse, hepatitidem terrore esse excitatam."—Summa. Obs. Med., vol. ii. p. 197. Hippocrates speaks of terror as an exciting cause of this affection: De intends adfectionibus. Sect. iii. cap. 1. § A very striking and interesting case of this kind is related in the Annuaire Medico-Chirurgicale for 1822. II Hufeland's Journal der Pract. Heilkunde, vol. xviii. p. 62. ACUTE HEPATITIS. 267 has been drawn to an extent sufficient to make a manifest impres- sion on the system, an active mercurial cathartic must be adminis- tered. From fifteen to twenty grains of calomel, followed in about two hours by a full dose of castor oil, or of infusion of senna and manna, constitute an appropriate and efficient purgative in this dis- ease. It is often necessary to repeat the bleeding several times in the course of the first few days, before the arterial reaction becomes permanently moderated ; and this is particularly apt to be the case in the disease as it occurs in temperate latitudes. In warm climates, a frequent repetition of venesection is not often necessary or even proper—one or two efficient bleedings in the commencement of the disease being in general sufficient to bring down the febrile reaction. The application of leeches to the epigastric and hypochondriac regions, will often contribute very materially to the reduction of the hepatic inflammation ; but one or two efficient bleedings from the arm should be premised to the local abstraction of blood. It may be necessary to reapply the leeches, where, after the adoption of the measures just indicated, the pulse still retains some activity, and the local symptoms are not considerably relieved. The bowels should be kept in a loose state throughout the whole course of the disease ; and calomel must always constitute a princi- pal ingredient in the purgatives employed. From eight to twelve grains of this preparation may be given at first, every six hours, and followed by the exhibition of a small dose of Epsom or Glauber's salts; or of castor oil, or infusion of senna and manna, if after ten or twelve hours the calomel do not procure free evacuations. After the general arterial reaction has been moderated by direct and local depletion, and the bowels well evacuated, our principal dependence should be placed on the speedy induction of modern ptyalism, in conjunction with blisters applied over the region of the liver, and moderate purgation. The practice of giving opium with calomel in this affection, particularly after the violence of the phlogistic excite- ment has been broken down by venesection, was long ago recom- mended as decidedly beneficial by Dr. Robert Hamilton; and it has since his time received the warm sanction of many of the most emi- nent practitioners. " I know from pretty ample experience," .says Dr. Johnson, " that in conjunction with antimonial powder, opium forms a most admirable auxiliary to mercury in acute hepatitis; not only soothing many uneasy sensations of the patient, but determining to the surface and promoting a diaphoresis, which is of infinite service in this, as in most other affections."* Dr. Armstrong also expresses his confidence in the usefulness of this narcotic in hepatitis; and, in my own practice, I have had unequivocal evidence of its beneficial effects in this malady. From three to four grains of calomel, with a grain of opium, may be given every four or five hours, and continued until the gums are obviously affected. The addition of two or three grains of the pulvis antimonialis, to each dose of the calomel and opium, will do good not only by its diaphoretic powers, but also, as * The Influence of Tropical Climates, &c, vol. i. 268 ACUTE HEPATITIS. it would seem, by its tendency to favour the induction of the mercu- rial influence ; and our main object must be to bring the system under this influence as early as possible. Whilst these articles are given, it will generally be necessary to exhibit an occasional dose of castor oil, or one of the saline purga- tives. In the more violent and rapid cases of this disease in hot cli- mates, it is often very difficult to obtain the timely operation of mer- cury on the system, merely from its internal exhibition. Where there is reason-to apprehend difficulty in this respect, mercurial frictions should be used in addition to the internal employment of calomel. One or two drachms of the ung. hydrarg. may be rubbed in on the arms or thighs three or four times daily, where ptyalism appears to be tardy in its appearance. Dr. Johnson states, " that the absorption of mercury into the system, and the consequent early induction of general mercurial action, are accelerated by causing the patient to swallow a considerable quantity of warm diluting drink, as thin water gruel, every night, at bedtime." The application of blisters large enough to extend over the whole right hypochondriac and epigastric regions, is a highly useful measure^ after bleeding has been efficiently practised. They almost always give considerable relief to the local pain, and by creating a perma- nent determination to the external surface immediately over the inflamed liver, they tend in no small degree to subdue the local affec- tion. As auxiliaries to bleeding, purgatives, and calomel, antimoninls will, in general, be useful where the stomach is not too irritable. The pulvis antimonialis, in doses of about three grains, may be given either in combination with calomel and opium, or in union with nitre, or the sulphate of potash, every three or four hours ; and to promote the diaphoretic operation of these remedies, as well as the specific effects of the mercury, the warm or tepid bath will frequently be found Very useful. When the inflammation has terminated in suppuration, (an event which is announced by the occurrence of rigors, a sense of sinking and anxiety in the praecordia, night sweats, and occasionally formi- cation of the skin, with a fullness and feeling of weight about the margin of the ribs, and a dull throbbing pain in the liver,) the further employment of mercury, with a view to its general influence, is im- proper. " If the local symptoms and the state of the pulse and of the system seem to require it, the application of a few leeches in the vi- cinity of the tumefaction will be generally serviceable ; and afterwards poultices should be assiduously employed, with a view of promoting the external pointing of the abscess."—(Annesley.) The bowels also should be regularly, though gently evacuated, after the formation of abscess has taken place, which may be best done by five or six grains of calomel, followed in a few hours by a small portion of one of the neutral purgative salts. When the abscess does not point externally, nothing more can be done than "to palliate symptoms as they rise, and wait for the event." In instances where the abscess does point outwardly, and the fluctuation of the matter can be distinctly felt, an CHRONIC HEPATITIS, 269 opening should be made into it,and exit given to its contents. "But this operation ought not, however, to be undertaken precipitately, and before the purulent formation has made its way sufficiently near to the external surface of the organ, or before the part at which it points has formed adhesions to the opposite part of the abdominal parietes. The practitioner should also be fully convinced, from the state of the tumour in the hepatic region, and from the history of the case, that abscess actually exists, and that the tumour does not proceed from an excessive accumulation of bile in the gall-bladder. When the pain and general fullness are diminished, and replaced by a distinct tu- mour, without acute pain, soft and fluctuating at its apex, or with a soft elasticity and slight lividity or redness of the surface, and a some- what hardened and elevated base, the operation may be undertaken with every expectation of success." The operation of paracentesis thoracis has been successfully per- formed in cases where the abscess had burst into the cavity of the thorax. An interesting case of this kind is related by Mr. Hoggins, in the London Med. Repos. for July, 1827. After suppuration has taken place, and the matter found a favour- able exit, there is, perhaps, no remedy which will afford so much advantage as the nitro-muriatic acid. It may be employed both inter- nally and externally as a foot-bath, in the manner recommended by Dr. Scott. Equal parts of the nitric and muriatic acids are the propor- tion in which they are usually employed. From a half to a whole drachm of this mixture, diluted in a sufficient quantity of water, may be taken daily ; and in order to prevent the acid from coming in con- tact with and injuring the teeth, it should he sucked through a small glass tube, or a quill: or the feet and legs may be immersed from thirty to forty minutes every evening in a warm bath, of the strength, at first, of half an ounce 'of the acid mixture to a gallon of water, and afterwards gradually increased in strength to the amount of six or eight drachms to the gallon. In two instances of hepatic suppuration from acute inflammation, the patients recovered com- pletely under the protracted use of this bath. Considerable advan- tage may also be obtained, in suppuration of the liver, from small doses of the muriate of mercury in union with the extract of cicuta, in the proportion of one-tenth of a grain of the former, to two grains of the latter, three times daily. Mr. Annesley has derived advantage from the nitric acid in combination with laudanum, hyoscyamus, or conium, particularly when the abscess has opened into the lungs. When in cases of this kind, the system becomes muchexhaus'ed, and the night-sweats are copious, or where the digestive powers fail, re- course ought to be had to some of the tonic bitters, in conjunction with nitric acid, and the extract of conium. Sect. XI.— Chronic Hepatitis. Chronic inflammation of the liver, when not the consequence of an acute attack of the disease, begins, generally, with symptoms of 270 CHRONIC HEPATITIS. functional disorder of the digestive and biliary organs ; and dyspepsia frequently seems to be the only affection present. The patient com- plains of irregular appetite, and impaired powers of digestion; acidity; flatulence; slight colic pains; occasional nausea and vomiting; and a sense of fullness in the region of the stomach. In many instances, a slight dull pain and weight are felt in the right hypochondrium,accom- panied, in some cases, with a dragging pain in the right shoulder. Most commonly, however, no distinct pain is experienced in the region of the liver, except when firm pressure is made on this part. In such instances, a sense of uneasiness and tightness is usually felt in the right hypochondrium; and if examination be made, a manifest tumefaction is often discovered in this part. The white of the eyes, and skin of the face, neck and breast, become tinged with a yellowish hue, and the countenance acquires a contracted and sickly aspect. The bowels are always very irregular, costiveness being most com- mon, alternating in some instances with diarrhoea, the discharges being frequent, scanty, dark-coloured, offensive, slimy, greenish, or watery and muddy. The urine is generally highly tinged with bilious matter, and Greates a sense of scalding in the neck of the bladder on being voided.* The tongue is for the most part white, and rather dry; the taste bitter or disagreeable ; and in the advanced periods of the disease, the gums often have a peculiar and unnatural firmness. One of the most constant and characteristic symptoms of chronic hepatitis, is a dry, harsh, and constricted stale of the skin. (John- son.) So torpid are the cutaneous exhalents in this affection, that every effort to produce a general moisture, or even softness of the skin, is generally abortive. A short dry cough, with slight difficulty in breathing, is a frequent attendant on this disease. In the chronic, as in the acute form of this disease, the patient can seldom rest as easy on the left as on the right side. As the disease advances, ema- ciation becomes more and more conspicuous; slight febrile exacerba- tions come on towards evening, attended with a burning heat in the palms of the hands and soles of the feet; the nights are restless; and when the inflammation terminates in suppuration, hectic and rapid emaciation consume the vital powers. When the convex surface of the liver is the principal seat of the inflammation, the pain will be referred to the thorax; but when the concave surface is the part chiefly affected, the patient generally refers the pain to the stomach or bowels. Chronic inflammation of the liver often occurs as a consequence of the acute variety of the disease; but it more frequently arises from the slow operation of the same causes which excite acute hepatitis. From the great frequency of chronic affections of the liver in warm and miasmatic situations, there can exist but little doubt, that the slow and continued operation of marsh miasmata is a principal cause of this affection. That this miasm has a particular tendency to produce biliary derangement, seems evident from the sallow and jaundiced * Mr. Rose and Dr. Henry assert, that urea and lithic acid are not found in the urine of persons labouring under hepatitis. CHRONIC HEPATITIS. 271 appearance of those who reside in marshy districts. The liver being in a state of almost constant excitation in situations of this kind, and finally disordered in its functions, is especially predisposed to conges- lion and slow inflammation, on the supervention of any other cause capable of deranging the cutaneous or digestive functions. Post-mortem appearances.—Chronic inflammation may terminate variously. No recent traces of inflammation are detected in the liver on post-mortem examination. The viscus usually exhibits an ash or clay colour, and is generally somewhat changed from its healthy, or natural shape. Dr. Saunders observes, that the lower margin of the left lobe, which in the healthy liver is thin, is commonly found rounded and gibbous in chronic hepatitis. In some instances the liver is of a much more firm and solid consistence than natural, although its weight is often specifically lighter than the healthy organ. In some cases, particularly in hot climates, the liver suffers much greater organic destruction than mere change of consistence and colour. Dr. Lind found the liver, in persons who had died of this disease, so eaten through as to resemble a honeycomb. Suppuration is a common termination of Chronic hepatic inflammation in India. " Not unfre- quently, very minute abscesses are scattered through the substance of the liver, both with and without the appearance of a distinct cyst, the matter collected being of a firm or cheesy consistence, and yellow- ish-white colour. (Annesley.) Sometimes, however, one large ab- scess is found in the structure of the liver. Tubercles of various sizes and appearances, are occasionally found imbedded on the surface, and interspersed through the substance of the liver. These morbid depositions vary in consistence " from a gristly or cartilaginous state, to one of semi-fluidity;" the firmer ones when divided often present- ing either a concentric or radiated texture. In the most chronic cases, the substance of the liver sometimes acquires almost a cartilaginous consistence. Annesley states, that in those who had been addicted to the use of spirituous liquors, the substance of the liver, besides small tubercles, exhibited " a cheesy consistence and texture of a deep nan- keen-like colour." Occasionally the liver is firm, and much dimi- nished in size, and its internal structure has sometimes exhibited a par-boiled, scabrous, dry and spongy appearance.* Treatment.—General depletion is very rarely indicated in this variety of hepatic inflammation. In cases of a subacute character, more especially when they occur as a consequence of an acute attack of the disease, it will sometimes be useful to abstract small portions of blood; but even in instances of this kind it will be better to de- plete by leeches applied to the epigastrium. " In the chronic hepa- titis of India," says Annesley, " there are few cases where repeated though moderate leeching will not be advantageous." After each leeching, an emollient poultice should be applied over the right hypo- chondrium, and a mercurial aperient administered at night. When the phlogistic action of the liver has been reduced, (where such * Researches into the Causes and Treatment of the Diseases of Warm Climates By James Annesley, Esq., p. 470. 272 CHRONIC HEPATITIS. reduction may be indicated by the local pain, and action of the heart and arteries,) by moderate depletory and aperient measures, recourse should be had to a more regular administration of mercurial reme- dies. In the employment of mercury in this affection, however, it must be managed so as not to produce active ptyalism. Full saliva- tion seldom proves beneficial, and may do injury in this form of the disease. A moderate, uniform and prolonged mercurial influence will generally procure all the advantage that this remedy is capable of affording. From three to four grains of blue pill, in combination with a gram of the extract of conium, or of hyoscyamus, should be given three times daily, until the gums become slightly affected.* The medicine is then to be discontinued until the soreness of the gums is going off, when it is to be resumed, and given once or twice daily, so as to keep up a uniform impression on the system without producing ptyalism. During this mercurial course, mild laxatives should from time to time be given, so as to keep up a regular action of the bowels. For this purpose, small doses of Glauber's or Ep- som salts, or of powdered rhubarb, may be given every second or third day, according to the state of the bowels. Mr. Annesley re- commends the following aperient pill in this affection : R.—Hydr. submuriatis Qi. Extract, colocynth. comp. 9ij. Antim. tart. gr. i. Pulv. ipecac, gr. iv. Sapon. castil. gr. x. 01. carui q. s.—M. ft. pilul. xviij. S. Two of these pills may be taken every night on going to bed. In most cases one pill will be sufficient. To preserve the tone of the stomach, as well as the regular action of the bowels, it will be useful to prescribe a weak infusion of some of the tonic bitters—-as gentian, colomba and quassia. A tablespoon- ful of an infusion of this kind, with ten or twelve drops of nitric acid, may be taken morning, noon and evening. Dr. Johnson recommends the following formula as an excellent tonic in this affection : • R.—Decoct, taraxac. ^iv. Carbonat. sodae 3i. Extract, taraxac. jij. Tinct. gentian 31J.—Misce. S. Take two or three tablespoonfuls twice daily. " The more the taraxacum is employed," he says, «the more cer- * I have been in the habit of uniting small portions of ipecacuanha to the blue pill and conium, in this and other chronic complaints. Thus: R.—Massae hydrarg. ji. Extract, conii maculat. Jss. Pulv. ipecac. 9 i.—M. Divide into 30 pills. S. Take two every morning, noon and evening. CHRONIC HEPATITIS. 273 tain proofs will it afford of its utility." The aperient and diuretic qualities of this root are unquestionable.* In speaking only of a moderate mercurial action, I refer particu- larly to this affection as it is usually met with in the temperate lati- tudes. In the intertropical regions, chronic hepatitis is generally much more rapid in its progress, and is much more apt to terminate in abscess than in the colder climates. In consequence of this it is often necessary to employ the mercury more freely, and to carry it to the extent of producing salivation. Chisholm and Johnson re- commend the production of moderate ptyalism, and there can be no question of the general propriety of this practice in hot climates. The nitro-muriatic acid bath was some years ago strongly recom- mended to the profession, as a remedy in this variety of hepatitis, by Dr. Scott, and it has since received the approbation of many other practitioners, whose opportunities for testing its virtues in this way were very ample. " As a general rule," says Dr. Scott, " it may be observed, that whenever the mercurial preparations are indicated, the nitro-muriatic acid will be found useful—with this difference, that in cases where mercury is highly injurious, from delicacy or peculiarity of constitution, or from other causes, the nitro-muriatic acid may be employed with safety and advantage." Dr. Johnson, who speaks very favourably of this remedy in chronic hepatitis, gives the follow- ing directions for using it. " Into a glass vessel capable of holding a pint or more of fluid, put eight ounces of water: and then pour in four ounces of nitric, and the same quantity of muriatic acid. One ounce of this mixture to a gallon of water will form a bath of a medium strength. The feet and legs of the patient are to be im- mersed in this bath at the temperature of about 96°, and kept there twenty minutes, or half an hour, just before going to bed. This should be done every night, and the same bath will remain good for five or six nights." If no prickling or itching sensation is felt in the feet and legs after they have been immersed for twenty or thirty minutes, more of the acid must be added to the bath. The nitro- muriatic solution may also be used with benefit in the form of a wash. Two or three drachms of the above mixture should be added to a pint of warm water, and the body and thighs sponged with it, night and morning, for fifteen or twenty minutes at a time. Mr. Annesley states, that " he found great advantage from employing this solution in the form of a poultice in torpor of the liver, and in chronic affec- tions of the organ attended with enlargement, and a deficient and morbid state of the biliary secretion." Mr. Annesley speaks in the most favourable terms of this remedy in chronic affections of the liver. Where the structure of this organ is enlarged, and the biliary and intestinal secretions disordered, he declares this mixed acid " one of the most valuable remedies we possess." I have frequently used it in affections of this kind, and generally with marked advan- tage. The internal use of the nitrous acid also has been found very * Med. Chir. Rev., Jan., 1829. VOL. i.—18 274 SPLENITIS. beneficial in this affection. From two to four drachms diluted in a large portion of some mucilaginous fluid, may be taken in the course of twenty-four hours. It seldom fails to induce more or less ptyalism, when its employment is continued for some time; but it often acts beneficially without the production of salivation. It may be given simultaneously with mercury. (Annesley.) Sir James M'Grigor, indeed, thinks that peculiar advantages result from the conjoined use of these remedies. Blisters are beneficial in chronic hepatitis; but I have generally seen more advantage derived from pustulation of the right hypo- chondrium by frictions with tartar emetic ointment. The white pre- cipitate ointment forms a most excellent counter-irritating applica- tion in this affection. Two drachms of white precipitate, rubbed up with an ounce of lard, and applied two or three times daily by frictions to the region of the liver, will seldom fail to bring out a copious crop of large suppurating pustules, more permanent than those which are produced by tartar emetic, and much less painful and irritating. A seton in the right hypochondrium has been found very useful in the more chronic instances of this affection. The diet should be light, unirritating and digestible; and the patient must especially avoid a cold and damp atmosphere; or the influence of sudden changes of atmospheric temperature. In gene- ral, persons who are affected with this disease are peculiarly sensi- tive to low temperature; and it is a matter of considerable conse- quence to the successful issue of our remedial efforts, to place such patients in a temperature perfectly agreeable to their sensations and uniform in its grade. Sect. XII.—Of Splenitis. The physiological relations of the spleen are as yet but very im- perfectly understood; nor have the diseases to which it is subject been " either carefully studied or clearly revealed." *« Our ignorance of its use during health has rendered us less alive to its conditions in disease; and the obscurity of its functions when natural, has made their study when disordered less, interesting in its object, and less successful in its issue." It does not appear that this viscus is often the seat of active or acute inflammation,* although chronic inflam- mation is probably much more common than is generally suspected.t When acutely inflamed, the patient commonly feels a heavy pain under the false ribs of the left side, which is considerably increased * [I have never seen more than one case of acute splenitis; and that was a decisive one. The tenderness of the tumefied organ was peculiar and excessive, and the constitutional disturbance was very severe, for three days the symp- toms were alarming; but active depletion, general and topical, foUowed by active mercurial cathartics, finally gave relief.__Mc] t Richter thinks that chronic splenitis is even more common than chronic hepa- itis.—Die Spccielh Therapie, band. i. s. 576. SPLENITIS. 275 by external pressure. The left hypochondrium is said to become fuller than natural, and in some instances, considerable pain is felt under the right scapula. The skin and eyes become slightly jaun- • diced, and the urine highly tinged with bilious matter. A burning and oppressive sensation in the stomach, with nausea and vertigo, particularly when the patient raises himself in bed, and other dys- peptic symptoms, frequently attend the affection.* In chronic splenitis, slight uneasy and occasionally painful sensa- tions are from time to time experienced by the patient; and there is difficulty in lying on the left side, accompanied with dyspeptic symp- toms, a cachectic aspect of the countenance, and a gloomy, morose, desponding, or variable and fretful temper. Persons affected with chronic inflammation of the spleen are said to be prone to attacks of vomiting of blood —(Marcus, Richter,)—more especially when the inflammation has terminated in induration of this viscus. The blood, perhaps, passes into the stomach through the vasa brevia. From the foregoing symptoms, it is manifest that the diagnosis between this affection and hepatitis must always be attended with considerable uncertainty. The pain in the left side, and the vertigo when the head is raised, or on sitting up, are the only symptoms mentioned that are not as common in the latter as in the former affection. Inflammation of the spleen may terminate in suppuration, soften- ing of its structure, (ramollissemenl,) hypertrophy and induration. Suppuration, however, occurs but very rarely in this affection. M. Jaquinelle relates an instance in which a large abscess in the spleen had burst into the colon; and Wardrop found nearly the whole structure of this viscus converted into an abscess containing a purulent fluid. Dr. Tweedie, physician to the London Fever Hos- pital, has related a case of inflammation of the spleen which termi- nated in suppuration; and Dr. Raikem, of Volterra, has given an account of a similar case. In Dr. Tweedie*s case two abscesses were formed in the spleen, one in the centre, and another at the point of its adhesion to the diaphragm, the peritoneal covering and fibres of which it had destroyed. In Dr. Raikem's case, the interior of the spleen was hollowed out into one great abscess»"t Softening of the structure of this organ is a very common occur- rence, particularly "after some forms of general disease." In fatal cases of typhus, ramollissement of the spleen is almost always pre- sent.:); This softening consists of " a broken down semi-fluid pulp, resembling black currant jelly." (Abercrombie.) Enlargement of the spleen is particularly apt to occur in remit- tents and intermittents. It is probable, however, that this condition is rarely the consequence of inflammation—belug the result, gene- * Marcus, vide Annalen der Medizin, band. vii. s. 327. t Edin. Med. and Surg. Jour., April, 1830. X Dr. Vetch, physician to the Charter-house, mentions the following symptoms as generally accompanying enlargement of the spleen. There is little or no pain complained of by the patient; "the appetite is usually good, yet the powers of 276 SPLENITIS. rally, of great and protracted sanguineous congestion of this organ. During the cold stage of intermittents, the spleen always becomes greatly engorged with blood, and when this disease continues a long time, enlargement, induration, and sometimes a complete disorgani- . zation of this organ take place. Dr. Vetch states, that in the only three cases of intermitting fever which he has known to terminate fatally during the cold stage, the spleen was found so much distended with blood, and its structure so much altered, that it resembled a mass of dark uncoagulated blood, which was broken down by slight pressure of the finger. This state of the spleen is attended with great increase of its vascularity; whilst little or no morbid change usually occurs in its proper substance. Dr. Abercrombie observes, that " one of the most singular facts in the pathology of the spleen, is the very rapid manner in which enlargement of it takes place; and the equally rapid manner in which it subsides."* In some instances, tubercles and hydatids are found in the spleen; and authors mention a pale induration of this organ as an occasional phenomenon. (Diemerbroeck.) Dr. Abercrombie mentions, also, infiltration of a gelatinous fluid, and deposition of adipose matter into the substance of the spleen. Treatment.—Acute inflammation of the spleen is to be encoun- tered with the usual antiphlogistic remedies proper in visceral inflam- mations. Decisive blood-letting, purgatives, and counter-irritating applications to the region of the spleen, constitute the principal means for combating this affection. The warm bath, after the active state of the disease has been in some degree reduced, is said to be a useful auxiliary. In the chronic form of the disease, leeching and pustulation of the left hypochondrium by frictions with tartar emetic mntrnent; the warm bath ; mercurial laxatives; a seton in the left side; alterative doses of blue pill with extract of hyoscyamus; diaphoretics; and the protracted use of minute doses of tartar emetic, are the remedies upon which our chief dependence is to be placed. assimilation are obviously deficient; the patient loses flesh ;t is incapable of any muscular exertion; his features have a dark, bilious, or mahogany hue, but the conjunctiva preserves a white and healthy appearance; perspiration is in time wholly suspended, and the skin acquires the appearance and feel of satin; the lips are pale, and there is generally much wasting of the gums; the urine is limpid, and secreted very rapidly, but contains little or no urea. The patient's mind is desponding and morose; and there is coldness of the lower extremities." —Med. and Phys. Journal, 1824. * Med. Chir. Rev., January, 1829. f [Infants are sometimes affected with permanently enlarged and very indurated spleens, which produce extreme anemia without any remarkable degree of ema- ciation. Dr. Elliotson thinks such cases proceed from the parents having been exposed to marsh miasma. I have seen them where no such cause could be suspected. Chalybeates and iodine are the only remedies; but my success has been poor enough with them.—Mc] INFLAMMATION OP THE BRAIN. 277 In» enlargement and induration of the spleen, particularly when they occur as the sequelae of intermitting fever, I have found no remedy more useful than large doses of the muriate of ammonia. The for- mula given in the chapter on intermitting fever may be employed with a pretty certain prospect of success in cases of this kind. Small doses of tartar emetic, also, are decidedly beneficial in enlargement of the spleen. One grain dissolved in two quarts of some bland fluid or water, may be taken in place of the common drink, and continued for eight or ten days. Alterative doses of blue pill with ipecacuanha, in the proportion of two grains of the former to one of the latter, will frequently succeed in removing this state of the spleen. The bowels must be regularly moved by some mild aperient; and the diet should be mild, digestible, and nourishing. The warm bath, and frictions with dry flannel or the flesh brush, will assist in the removal of this affection. Iodine has recently been employed for the reduction of enlarge- ment and induration of the spleen; and it would appear to possess very active powers against this affection. It may be used either internally in the form of tincture; in doses of from eight to ten drops three times daily; or in frictions with the hydriodate ointment, over the region of the spleen.* CHAPTER XI. OF THE PHLEGMASIA OP THE NERVOUS SYSTEM. The pathology of encephalic inflammation is attended with much difficulty on account of the variety of structures which compose the encephalon, and the consequent diversity which occurs in the symp- toms and terminations of its inflammatory affections. Within the cranium there are no less than three distinct structures, namely, the fibrous, the serous, and the cerebral, and there is reason to presume, that the phenomena of cephalitis will be considerably modified, ac- cording as one or the other of these structures is the principal seat of the inflammation. It is not probable, however, that any one of the structures within the cranium can suffer inflammation, without in- volving, in some degree, the others; and all attempts, therefore, to assign to each structure its peculiar symptoms under inflammation, must necessarily be attended with considerable uncertainty. Never- theless, there are certain modifications of the phenomena of cepha- litis, which observation has taught us to refer to particular structures, and which may, therefore, be taken as a basis for the division of * [The most decisive effects in enlargement of the spleen have been produced in my hands by occasional doses of Clutterbuck's extract of elaterium, in combi- nation with a small proportion of calomel.—Mc] 278 INFLAMMATION OF THE BRAIN. encephalic inflammation into certain varieties, sufficiently distmct to demand separate consideration. Agreeably to these circumstances, cephalitis presents us with the following varieties, viz.: Meningitis and cerebritis.—Meningitis must be again divided into inflammation of the pia mater, with more or less inflammatory action in the rest of the membranes and the brain ; and arachnitis. The first of these subdivisions constitutes the affection commonly called phrensy (phrenitis;) and the last is known under the inappro- priate name of hydrocephalus. Sect. I.—Phrenitis (Phrensy). Phrenitis generally begins with pain and a sense of fullness in the head, attended, in most instances, from the commencement, with considerable nausea and vomiting. As the pain and febrile reaction increase, the eyes become red and sparkling ; the face flushed ; and the patient often experiences a peculiar sensation of uneasiness along the course of the spine. Delirium is commonly an early attendant on the disease, and in most instances, soon acquires a degree of vio- lence resembling the most furious and ungovernable mania. In this aggravated state of the disease, the face becomes turgid; the eyes wild and furious ; the carotids beat strongly; vision is imperfect and deceptive; and the whole system is in a continued state of restless- ness or agitation. During the early part of the disease, the sense of hearing is generally painfully acute, but in its advanced periods, complete deafness often occurs. At first, the pulse, along with its firmness and activity, has considerable volume*; but in the progress it becomes small and tense, and not unfrequently intermitting. Respiration, though hurried and anxious at first, becomes slow, deep, and somewhat laborious in the latter stage of violent instances of the disease; and in many cases deglutition is performed with much difficulty. The liver often sympathizes strongly with the brain in this disease, giving rise to a copious secretion of bile' jaundice, and other mani- festations of hepatic derangement. Dr. Wilson observes, " that there is often a remarkable tendency to the worst species of haemorrhages from the bowels, towards the termination of fatal cases;" an ob- servation which was confirmed by a remarkable instance which came under my own notice. On the day preceding the fatal termination of this case, an exceedingly copious discharge of dissolved blood took place from the bowels, and on the following morning the haemorrhage occurred also from the mouth and gums. Causes.—Phrenitis is not often an idiopathic affection. It occurs most commonly during the progress of general fevers, particularly synocha, and the aggravated instances of typhus. The ordinary ex- citing causes of this variety of encephalic inflammation are, violent passions ; insolation; the sudden influence of cold while the body is in a state of free perspiration; drunkenness; suppression of habitual INFLAMMATION OF THE BRAIN. 279 sanguineous discharges ; and particularly metastasis of gout, erysipe- las, and parotitis, and the extension of other external inflammations about the head to the brain, an occurrence sometimes met with in small-pox. I have known the disease to supervene in consequence of a large phlegmonous swelling under the left ear; and another in- stance, from a similar inflammation on the back of the neck. Prognosis.—Haemorrhages, in the advanced period of the disease, particularly from the bowels, may be regarded as almost a certainly fatal sign. Bleeding from the nose, however, at an early period, seldom fails to mitigate the violence of the disease, and should always be promoted as a most favourable occurrence. Coma supervening on violent delirium, is indicative of great danger; for after the occur- rence of this symptom, little or no hopes of recovery can be enter- tained. Phrenitis is always attended with considerable danger; and the unfavourableness of the prognosis must of course be proportionate to the violence of the symptoms, and the obstinacy with which they resist remedial treatment. Morgagni observes, that when phrenitis supervenes on peripneumony, the worst consequences are to be ap- prehended; and the same observation is made by Schmidtmann.* Pathology.—It is stated above, that in the disease just described, the inflammation is principally located in the pia and dura mater; and this appears to be entirely confirmed by the phenomena which are presented on post mortem examination. I am aware, that Bi- chat asserts that the dura mater is scarcely susceptible of inflamma- tion ;t but this assertion is contradicted by others, and with justice. Shaw, in his Manual of Anatomy, states, that after phreniiis, the traces of inflammation are always very conspicuous on the surface of the dura mater, "which is generally as much blood-shot as the con- junctiva in ophthalmia, with layers of lymph occasionally on the inner surface." The observations of Morgagni, also, go to establish the same fact ; for, in nearly all the dissections which he relates of subjects who had died of this disease, the pia and dura mater showed the strongest signs of previous inflammation. The substance of the brain itself does not often exhibit unequivocal traces of inflam- mation in those who die of phrenitis; but in nearly all instances, flakes of coagulable lymph, and often pus mixed with serum, are found between the membranes, and in some cases the dura mater has been found eroded to a considerable extent. (Morgagni.) In- deed, inflammation of the cerebral substance alone is very rarely attended with the violent delirium and pain which distinguish the affection under consideration; nor is delirium a very constant and prominent phenomenon of arachnoid inflammation, though fre- quently connected with very severe and lancinating pains in the head. It cannot, indeed, be doubted, that the brain becomes more or less involved in the inflammation which constitutes this disease, but the principal seat of the inflammation would seem to be placed * Summa Observationem Medicarum, vol. i. Berlin, 1819. f Pathological Anatomy, translated by I. Togno, M. D., p. 58. 280 INFLAMMATION OF THE BRAIN. in the pia and dura mater. Morgagni states, that he has found the membranes alone affected, although, in the majority of cases, traces of inflammation were also discovered in the cerebral structure. Treatment.—There is no inflammatory affection which more urgently demands a vigorous antiphlogistic treatment than the pre- sent one. Blood-letting, promptly and efficiently used, is a sine qua non in the remedial management of this affection, as indeed it is in all the modifications of cephalitis. Many of the other phlegmasial diseases may often be treated successfully without sanguineous deple- tion. Pneumonia is treated by some* with opium and calomel; and by others,! wuh tartar emetic, with little or no abstraction of blood. But phrenitis is, perhaps, never treated with success without efficient blood-letting, nor is it likely that any other remedial measures would be of adequate avail, without the aid of this most prompt and effi- cient of all our antiphlogistic means. Blood should be drawn from a large orifice, and suffered to flow until unequivocal signs of its effect on the action of the heart and arteries are manifested. Carried to the extent of inducing an approach to syncope, bleeding will gene- rally speedily subdue the furious delirium and intense pain in the head. In all inflammatory affections,of the head, particular advan- tage may perhaps be obtained by taking the blood from one of the jugulars or the temporal arteries. Although bleeding is always most serviceable when adequately performed in the onset of inflammatory affections, yet in the present disease it may be advantageously resorted to throughout the whole course of the malady, if the pulse remains tense and quick.t Topical bleeding by leeches or cups, is less bene- ficial in this than in the less violent forms of encephalic inflammation in its early stage. § After the momentum of the circulation has been diminished by general bleeding, leeches or cups, applied to the tem- ples and about the head, will in general procure considerable advan- tage. The application of cold water or ice to the head is a valuable auxiliary in the treatment of this disease. The hair should be cut * Schmidtmann, Vogel. t Rasori, and the advocates of the contra-stimulant doctrine. X [After the first blood-letting the pulse should be carefully watched, and at every subsequent reaction the bandage should be removed, and more blood drawn from the same orifice. I have in this way repeated the evacuation several times on the first day with the most decisive effect.—Mc] § Mr. Chauffard states that he has often seen an inflammatory affection of the head aggravated by leeches to the temples or behind the ears, and relieved at once by drawing blood from the feet and ankles. He mentions several cases of ophthalmia, unchecked and uncured by local bleedings from the neighbourhood of the eyes, speedily disappear by the application of leeches to the lower extremi- ties. The good effects are much enhanced by the warm hip or foot baths; cold applications at the same time kept constantly applied to the head.—Med. Chir. Rev., 1832, p. 188. Dr. Johnson observes that "revulsive bleeding7' may be used with exceeding good effects, especially in those cases of cerebral disease dependent on obstruc- tion of any accustomed discharge. INFLAMMATION OF THE BRAIN. 281 short, or shaved off, and bladders partly filled with cold water, into which a lump of ice is put, should be kept constantly applied to the top of the head. Purgatives of the active kind will assist materially in reducing encephalic inflammation. In all affections of the head, whether congestive or inflammatory, there is usually considerable torpor of the intestinal canal, and it is generally necessary to prescribe large doses of some active purga- tive to procure an adequate evacuation of the bowels. As the liver usually sympathizes strongly with the brain in its inflammatory affec- tions, calomel forms an appropriate constituent in the purgatives pro- per in this disease. From ten to twelve grains of this article, followed after the lapse of three or four hours with infusion of senna, or a full dose of Epsom or Glauber's salts, will in general answer well as a purga- tive in this affection. Care must be taken in the use of calomel, lest ptyalism be induced, an occurrence which could hardly fail proving injurious. The bowels should not be suffered to remain inactive for more than five or six hours at a time, and this should be attended to, not only during the active course of the disease, but throughout the period of convalescence. Cathartics do good in this affection, both as revulsive and evacuant means. By exciting the intestinal exha- lents, and thus directing the circulation more particularly to them, purgatives tend, in nO inconsiderable degree, to diminish the flow of blood to the head, as well as the general momentum of the circula- tion, by their indirect depletory effects, and the removal of irritating matters from the intestinal canal. Many writers recommend the application of blisters to the head, after the violence of the febrile excitement had been in some degree subdued by the depletory measures. In the early periods of the dis- ease they are useless, and perhaps injurious, but when the violence of the inflammation is moderated, and the disease, as it were, linger- ing on the confines of convalescence, advantage may, perhaps, be derived from vesicatories applied to the shaven scalp. It has ap- peared to me, however, that more benefit is derived in the inflam- matory affections of the brain, from blistering the back of the neck, than from vesicatories laid on the top of the head. When applied on the neck we may at the same time continue the use of cold appli- cations to the scalp, a union of applications particularly appropriate to this disease. The patient's head should be kept in an elevated position, in order to lessen the impetus of the circulation in the affected parts. In all inflammations, considerable benefit accrues from placing the inflamed part, if feasible, in a raised position, as we thereby favour the return of the blood from the inflamed structure by the veins, and impede, in some degree, the access of the blood by the arteries, in consequence of the additional resistance offered by the gravity of the blood to the propulsive efforts of the heart. Among the internal antiphlogistic means, nitre,in combination with antimony, or digitalis, may be accounted the most useful. From ten to twelve grains of the nitrate of potash, with half a grain of digitalis, may be given every two hours. Digitalis is particularly well 282 INFLAMMATION OF THE BRAIN. suited to the management of this, as well as of other inflammatory affections, after the violence of the disease has been broken down by the remedies already mentioned, and when it continues its course in a reduced or subacute form. Given in small and frequent doses, it will, under these circumstances, often make a very decided and salutary impression upon the action of the heart and arteries. From a quarter to half a grain of the powdered leaves may be given every two hours, until it either causes a reduction of the frequency and activity of the pulse, or produces nausea or other symptoms of gastric dis- turbance. During the whole course of the disease, the chamber of the patient should be kept dark, silent, and cool, and every thing avoided which has a tendency to disturb or excite the system. No nourishment whatever, with the exception of toast-water and lemonade, or similar beverages, must be allowed, so long as there are pain in the head, and general febrile irritation. Sect. II.—Arachnitis. Hydrocephalus acutus; acute dropsy in the brain ; apoplexia hy- drocephalica—(Cullen.) Encephalitis—(Porter.) Phrenicula — (Rush.) Hydencephalus — (Smith.) Cephalitis profunda— (Good.) Arachnitis is a much more common form of encephalic inflamma- tion than the preceding one.* It has of late years been extensively in- vestigated by Martinet and Duchatelet, of Paris, and by Dr. Abercrom- bie, of Edinburgh, whose pathological researches in relation to this subject are highly interesting and valuable. I treat of hydrocephalus and arachnitis under the same head, for it is now placed beyond all doubt, that the malady known and described under the name of hy- drocephalus, consists essentially of arachnoid inflammation. The term hydrocephalus is, indeed, altogether inappropriate to the disease; for, instead of directing the mind to the primary and essential affec- tion, it has reference only to one of its ordinary consequences—namely, serous effusion on the surface and within the cavities of the brain. Dr. Rush was one of the first who taught correct views concerning the pathology of this disease. " Having for many years," he says, " been unsuccessful in all cases but two of internal dropsy of the brain which came under my care, I began to entertain doubts of the common theory of this disease, and to suspect that effusion of water should be considered only as the effect of a primary inflammation in the brain." He regared this disease as a subacute grade of cerebral * Dr. Coindet states, that in France, 20,000 deaths occur of this disease annu- ally, while Dr. Alison informs us, that 40 out of 120 patients die of this affection in the New-Town Dispensary; and, according to the late Dr. Davis, of London, 8 out of 45 deaths in the Universal Dispensary were produced by hydrocephalus. Med. Chir. Rev., March, 1828, p. 385. INFLAMMATION OF THE BRAIN. 283 inflammation, or an inflammation less violent than that which gives rise to the symptoms of phrenitis, and therefore distinguished it by the name of phrenicula* The impropriety of designating this dis- ease by the name of dropsy, is often strikingly exemplified by the post-mortem phenomena ; for, in some instances, very little or no se- rum is effused into the ventricles, or upon the surface of the brain, although the symptoms were unequivocally those which are acknow- ledged to characterize hydrocephalus.—(Abercrombie.)t It is, nevertheless, probable that effusion within the cavity of the cranium does sometimes occur without inflammatory action of the vessels of the encephalon, from mere congestion of the cerebral blood-vessels. This is, perhaps, the case in some of the instances which are ushered in by convulsions, or a state of somnolency and stupor, without any manifest previous febrile irritation. Be this as it may, arachnoid inflammation constitutes unequivocally the essential pathological condition of what is generally known under the deno- mination of hydrocephalus. Arachnitis occurs most commonly during childhood ; and the pe- riod of dentition is the age during which the greatest aptitude exists to the disease. That there should be a particular proneness to this malady during the process of dentition is easily to be understood. Whilst this process is going on, there is almost always more or less local irritation in the immediate vicinity of the brain, connected with a general irritable and phlogistic condition of the system—circum- stances which, co-operating with the natural predominance of the cerebral circulation in infancy, are well calculated to invite to inflam- matory affections of the head during this period of life. Symptoms.—Arachnitis may be divided into three stages. The first stage may be called the irritative period; for, in the commence- ment of the disease, the symptoms are those of an irritated, rather than an inflamed condition of the brain. The approach of the dis- ease is frequently very gradual, more especially during early child- hood. In many instances, the brain manifests a very irritable con- dition for several weeks previous to the full development of the disease. The patient is wakeful; irritable in temper; evincing a repugnance to strong light, on account of the sensible state of the retina; the pupils are contracted ; the disposition fretful and variable ; small children cry frequently, without any apparent cause, and, when sleeping, often start or awake suddenly, with violent screaming," and an expression of terror in the countenance." Nurslings, when * Dr. Porter contends that hydrocephalus is not phrenitis, (though he admits that meningitis may be superadded,) but an inflammatory condition of the poste- rior arteries of the encephalon, and of the base of the brain.—Med. Chir. Journ., July, 1819. t [In the majority of all the cases in which I have made post-mortem examina- tions for acute hydrocephalus in children, I have been disappointed in regard to the anticipated effusion. Inflammation of the enveloping and penetrating portion of the membranes has always predominated, and often the cerebral injection has terminated in bloody extravasation.—Mc] 284 INFLAMMATION OF THE BRAIN. awake, often " start at the slightest noise, and shriek suddenly as if pricked with a pin."* This state of cerebral irritability sometimes exists and continues for a time without passing into the inflammatory state ; the child gradually returning to its ordinary condition of health. When, in this state, some additional exciting circumstances supervene —such as cold, dentition, or intestinal irritation from improper food, or other irritating substances lodged in the bowels, this irritative con- dition of the brain is increased, and sooner or later converted into inflammation. A new train of phenomena now ensues, which cha- racterizes the inflammatory, or second stage of the disease. The patient complains of transient pains in the head, alternating often with similar pains in the abdomen. The restlessness and irritability of temper increase ; the pulse is irritated, quick, tense and active; the physiognomy expressive of discontent and suffering; one or both cheeks marked with a circumscribed flush; the eyebrows knit and frowning; and the eyelids generally half closed, on account of the sensible state of the retina. The bowels are commonly torpid, and sometimes relaxed, the stools presenting an unnatural appearance. As the disease goes on, the cephalic pains become more and more severe, suffering occasional remissions, and sometimes subsiding en- tirely for a few minutes. These pains are felt chiefly in the forehead, shooting backwards towards the temples. Children manifest their sufferings from the headache, by frequently applying the hands to the forehead. At this period of the disease, the stomach is usually very irritable—the retching and vomiting becoming often very trouble- some, particularly when the patient is raised to a sitting posture. I have met with many instances in which no disposition to vomit was manifested whilst the patient remained in a recumbent position; but the moment the head was raised from the pillow, sickness and vomit- ing ensued. Indeed, children affected with this disease always bear the erect position with great uneasiness. " In the early part of the disease, the little patient cannot sleep with the head low ; he lies in the bed with outstretched arms, which have a tremulous motion; are often directed towards the head, and firmly clasped upon it; he is constantly turning and tossing from one side of the bed to the other, and very frequently groans much, as if under the influence of pain." (Monro.) The sickness of the stomach sometimes alternates with the cephalic pains. (Quin, Fothergill.) One of the most common and characteristic symptoms of this complaint is frequent and deep sighing; though this is seldom much noticed until the disease is fully developed, and is generally most remarkable about the period when the inflammation is about terminating in effusion. During the latter part of the inflammatory stage, transient delirium usually occurs: but the delirium of arachnitis is never violent or furious, but of the tranquil kind, and rarely so great that the patient may not be roused * Dr. W. Nicholl's Transact, of the Association of Fellows and Licentiates of the King and Queen's College, Dublin, vol. iii. Practical remarks on disordered stales of the Cerebral Structures occurring in Infants. By W. Nicholl, M.D., London,, 1821. INFLAMMATION OF THE BRAIN. 285 from it, so as to give distinct answers. (Martinet.) The skin in this stage is generally above the natural temperature, and dry; the tongue, for the most part, remains clean, or covered only with a thin white fur, with pale red edges. In cases, however, which depend on gastric irritation, it is apt to be covered with thick brown fur, becom- ing dry and rough towards the termination of the disease. After an indefinite period, these inflammatory symptoms are succeeded by a new train of phenomena, marking the third stage or the period of cerebral oppression. The delirium is now more continuous; the countenance exhibits an aspect of surprise and stupor; the pupils are dilated or much contracted; the conjunctiva is suffused and reddish; the eyes turned up under the upper lids during sleep ; con- stant somnolency supervenes, the patient being wholly inattentive to surrounding objects, and when roused, speedily relapses into the same somnolent state. The mind is torpid, and apparently inca- pable of any attention. The drowsiness increases more and more, until a complete state of coma ensues. In some instances, the coma comes on suddenly in conjunction with.paralysis of one side of one extremity; but it more commonly approaches in the gradual manner just described. Indeed, instances occur, in which no febrile excite- ment is developed, the first manifestations of the disease being an unusual drowsiness or torpor. In this latter case, arachnoid inflam- mation exists, no doubt, without showing itself by its usual symp- toms; for it is well ascertained that inflammation may go on in the brain, even to the extent of terminating in extensive and fatal dis- organization, without causing either pain or any other general symp- toms characteristic of inflammation. Soon after the somnolent stage supervenes, paralytic affections generally occur. A tremulous motion of one arm, with the hand firmly contracted inwards, is usually one of the first manifestations of paralysis in infants; and, by degrees, the power of using the arm and leg of one side becomes entirely lost; one or both upper eyelids usually becoming paralyzed at the same time, so that the patient, in endeavouring to look at any thing, is unable to raise the lids by their proper muscles, and is, therefore, obliged to draw them up with the integuments of the forehead, by the contraction of the occipito-frontalis muscle.* Previous to the occurrence of paralysis, strabismus almost always occurs, and in many instances, there is double vision. In general, a sudden amend- ment in nearly all the symptoms takes place soon after the inflamma- tion has terminated in effusion; and parents and friends, nay, even physicians, may be deceived into the hope that the disease is about assuming an unexpected favourable change. This flattering calm is, however, seldom of long continuance, and almost universally ulti- mately fallacious; for, sooner or later,convulsions suddenly supervene, or the patient relapses into a state of fatal coma and stupor. Con- vulsions rarely, if ever, remain wholly absent towards the fatal ter- mination of this disease. During the somnolent stage, the pulse is * Recherches sur FInfiammation de l'Arachnoide, Cerebrale et Spinale. Par Parent Duchatelet et L. Martinet. Paris, 1821. 286 INFLAMMATION OF THE BRAIN. generally slow and full, and often irregular; but in the convulsive or paralytic period, it becomes frequent, small and irregular. In the latter stage of the disease, both hearing and seeing are often totally lost, yet general sensibility, or the sense of touch, usually remains to the last moments. I have seen infants, perfectly deprived of the sense of seeing, and apparently of hearing, readily lay hold of the nipple and suck as soon as it was brought in contact with the lips, although in a continued state of stupor or sleep. The paralysis which occurs in the latter stage is always of the hemiplegic kind. In most cases, small children keep one arm in continued motion. (Cheyne.) Martinet and Duchatelet state, that patients suffering under this disease exhale a very disagreeable odour, which they com- pare to the smell of mice. Arachnitis does not, however, always come on in the gradual man- ner and with the regular train of symptoms just described. Some- times the disease commences and proceeds in a manner very similar to the infantile remittent; and at others it is ushered in by convul- sions, without any perceptible antecedent febrile irritation. In this latter case, however, there is, perhaps always some evidence of ill health, previous to the supervention of the convulsion, such as fret- fulness, variable appetite, irregular state of the bowels, tumid abdo- men, foul breath, swelled upper lip, starting, and grinding the teeth, during sleep, and other symptoms indicative of intestinal irritation. I have known the disease to commence and proceed to the last stage with scarcely any other symptom than slight febrile irritation, with little or no pain in the head, but a constant and nearly ineffectual desire to pass urine. In one instance there was not above a gill of urine discharged in twenty-four hours during the first five days of the malady, and no other particular morbid condition was percepti- bly present. In this case the urine was not retained, for the intro- duction of the catheter brought off none. Dr. Monro observes, " that there are cases in which the little patient has a desire every hour to pass water;" and states that he "attended a child affected by this disorder, who passed for some days very little urine." The liver generally sympathizes strongly with the brain in its inflammatory affections. During the former stage of the present complaint there is usually a deficiency of bile; but in its advanced periods, the bile is not only more copious, but vitiated in its quality—the stools acquiring from its admixture with the ordinary secretions and contents of the bowels a dark glairy, or deep green appearance, resembling, as Dr. Cheyne observes, " chopped spinage." Diagnosis.— The characteristic symptoms of the first stage are: irritability of temper ; irregularity of the bowels; variable appetite; starting in sleep; transient flushes of.the face; an irritated, quick pulse, an occasional frowning expression of the countenance ; wake- fulness ; and grinding the teeth. In the second stage : more or less continued pain in the head; torpor of the bowels; nausea and vo- miting, particularly on assuming the-erect posture ; irregular febrile exacerbations ; a peculiarly distressed expression of the countenance, sudden starting from sleep ; transient acute pain in the abdomen; a INFLAMMATION OF THE BRAIN. 287 circumscribed flush on one cheek; intolerance of light and sound; hot and dry skin, with frequent, tense, and generally active pulse. In the last stage ; constant somnolency ; torpor of the intellectual func- tions; strabismus ; paralysis of one or both upper eyelids ; more or less hemiplegia, coma, and convulsions. From infantile remittent, arachnitis differs in the great irregularity, both in relation to duration and time of recurrence of the remissions and exacerbations of the second stage. The appearance of the stools, too, will often assist us in the diagnosis between these two affections. In infantile remittent, the alvine discharges are fetid and of a dirty brown colour; in arach- nitis, they frequently have a glairy and dark green appearance. (Cheyne.) Dr. Coindet states that a micaceous deposition like crystals of boracic acid in the urine, is almost peculiar to hydrocephalus in its second stage. M. Gintrae (Journal Generale de Medecine, 1825), gives the follow- ing, among a number of other diagnostic symptoms, between idiopa- thic arachnitis or cerebral fever, and infantile remittent, or fever from intestinal irritation. In idiopathic cerebral fever, the abdomen be- comes flattened; in infantile remittent, or fever from intestinal irrita- tion, from worms, &e, the abdomen is almost always tumid and hard. In the former affection,costiveness almost invariably attends, and when alvine evacuations do occur, they are generally green, slimy, or gela- tinous : in the latter disease, there is frequently more or less diarrhoea, the motions being brown, mucous and fetid. In idiopathic cerebral fever, the secretion of saliva is diminished : in fever from verminous irritation, it is generally increased. (Brera ) In cerebral fever, the tip and edges of the tongue are usually red : in fever from intestinal irritation by worms, the root and middle of the tongue are covered with a thick fur. In idiopathic cerebral disorder, the pain in the head is often extremely severe and continuous; in verminous fever, the pain is less severe, being obtuse and vague, the child seldom com- plaining of it as particularly distressing. In the former affection, the patient often directs his hand to the head : while in the latter," it is usually to the nose that the fingers are directed, in consequence of the itching there." In verminous fever, we often perceive a moment of deglutition during sleep, and hiccough, with occasional slight convuls- ive movements of the thumb and index finger. In the idiopathic cerebral disease, the nostrils are dry; in fever from verminous irrita- tion, they are usually moist. In the former there is often a circum- scribed flush on one or both cheeks : in the latter, the face is commonly pale and leaden. In cerebral disease, the temperature of the head is above that of the abdomen : in intestinal irritation, the reverse obtains. In the former, the urine is small in quantity, red, and sedi- mentous: in the latter, it is sometimes clear and abundant; frequently whey-like, depositing a white sediment. Dr. Johnson very justly observes, however, that " there is no one pathological symptom, which can be depended on as characteristic of idiopathic cerebral fever, nor yet of the intestinal." Our conclu- sions must be drawn from the whole of the symptoms taken collect- ively. 28S INFLAMMATION OF THE BRAIN. Dr. Alexander Monro has described a variety of hydrocephalus, which he calls the « hyper-acute form" of the disease, a form of very rare occurrence, and simulating, in some of its most striking symp- toms, inflammatory croup. " This rare form of the disease is very sudden-in its attack. There are no previous headache, drowsiness, stupor, nausea, vomiting, paralytic state of any part of the body, or any other symptom denoting a derangement of the functions of the nervous system. It begins like croup. The child awakens in the night in a state of extreme agitation, and much flushed, and with a quick pulse; he is hoarse, and the sound of the voice when he in- spires is similar to that of croup. The patient, at the onset of the disease, seems in a state of nervous irritation; often starts in his sleep, and in a short time the disease assumes the appearance rather of a spasmodic affection of the larynx than of the inflammatory croup. The matter thrown up by vomiting, consists generally of indigested food. The longer the disease continues, the shriller and hoarser the voice becomes." In the dissections which were made of children who died of "this form of the disease, Dr. Monro found in one instance, the vessels of the pia mater at the corpora quadrigemina and tractus optici, and at the origin of the eighth pair of nerves, much distended with blood. No morbid appearance was discovered in the larynx and trachea." In another case, " the upper part of the brain, particularly the supe- rior part of the posterior lobes, was covered with a transparent gela- tinous effusion ;" and about an ounce of coloured serum was found in the ventricles. " The vessels of the spinal marrow were turgid, those of the cervical portion of a vermilion-red colour, and those of the lumbar portion of a dark-red hue. The eighth pair of nerves was of a deep uniform red colour along its whole tract, as far as its branches, going to the lungs." Dr. Burns attributes this form of hydrocephalus " to an affection of the origin of the eighth pair of nerves, induced by the state of the extremity of the fifth pair in dentition acting on its origin, which is near the eighth."* Post-mortem appearances.—In some cases the arachnoid mem- brane is minutely injected throughout its whole extent; in others it is Opaque and thickened. On its surface, " a purulent, sero-purulent, or sero-gelatinous exudation" is a very common phenomenon ; and it is still more common to find a greater or less portion of serum effused into the ventricles, between the lamina of the arachnoid, and into the cellular tissue between this membrane and the pia mater. (Martinet.) In some instances, however, little or no serum is found effused. Out of twenty-six cases related by Martinet and Duchatelet, there were eight, in which scarcely any trace of effusion into the cavities, or on the surface of the brain occurred. In some instances, the substance of the brain was altered in its consistence and colour; and in a few cases the whole surface of the arachnoid was covered with a false membrane. * The Morbid Anatomy of the Brain. By Alexander Monro, M. D., 1827. INFLAMMATION OF THE BRAIN. 289 Causes.—It would seem, that in some instances a hereditary or constitutional predisposition to the disease exists. I have known families, of which nearly all the children died during the period of dentition from arachnitis. It has been affirmed, also, that children of a scrofulous diathesis, are peculiarly liable to this affection, an observation which appears indeed to be well founded. In general, children of an irritable habit, with weak or deranged digestive powers, seem to be most liable to this disease. Dr. Mills* states, that in a large proportion examined, the appearances of scrofula were evident. And Percival observes, that out .of twenty-two, eleven cases "were decidedly scrofulous."! Among the most common exciting causes, are: blows, falls, or other injuries of the head, causing more or less concussion ; insolation, [ictus solus;) suppressed habitual evacuations, or repelled chronic cutaneous eruptions; metastases of different kinds ; intense and long- continued mental application ; the intemperate use of ardent liquors; the protracted influence of the depressing passions; dentition, intes- tinal irritation ; hooping-cough ; cold, and in short, whatever is capa- ble of at once deranging the digestive organs, and causing a pre- ternatural determination of blood to the brain. The most common cause of arachnitis during childhood, however, is the combined in- fluence of dentition, and intestinal irritation on the brain. If, while painful dentition is going on, the digestive functions suffer derange- ment, from improper diet or some other circumstance, there will be two powerful causes of cerebral irritation and congestion present, which, under the general derangement of health which necessarily attends, will tend peculiarly to develop this fatal malady. Intesti- nal irritation is, indeed, very frequently the exciting, or perhaps, rather the predisposing cause of infantile arachnitis. The variable appetite; the irregular action of the bowels, and frequent unnatural * A Pathological Inquiry into the Nature of Hydrocephalus. By Thomas Mills, M. D., &c. Dublin Hospital Reports. t [-It has long been understood that a scrofulous diathesis is peculiarly liable to hydrocephalus. Indeed, Dr. Cheyne suggested that the hereditary disposition to this disease is altogether derivable from that source. He also with Sprengel con- sidered hydrocephalus and scrofulous affections as mutually convertible into each other. Careful practitioners have always been influenced by this idea to refrain from repelling strumous eruptions, and of suddenly healing up ganglionic abscesses and fistulas in young children. Laennec and others pointed out the existence of granular tubercles in the cerebrum, cerebellum and spinal cord; and the appear- ance of small opaque tuberculous masses along the course of the large veins of the pia mater and the longitudinal sinus, compared by some to the glands of Pacchioni, has long been recognized in hydrocephalus and other diseases of the brain. Dr. Gerhard, of this city, has lately called the attention of the profession to this subject more particularly, and gives strong countenance to the idea that the development of scrofulous tubercles is universal in the brains of hydrocephalic children. In conjunction with Dr. Rufz, in Paris, he derived this idea from an examination of about forty cases which terminated fatally in the children's hospi- tal of Paris. He proposes to denominate the disease tubercular meningitis.—Mc] TOL. I.—19 290 INFLAMMATION OF THE BRAIN. appearance of the stools: the tumid abdomen and gastric tender- ness ; the picking and rubbing of the nose, and the pale and sickly aspect of the countenance which so often precede the development of the disease, all point to the alimentary canal as the probable source of the primary irritation with which the brain sympathizes. When such gastric irritation exists, the supervention of any additional ex- citing cause, such as a severe fall; or blow on the head, painful den- tition, cold, &c., will often speedily develop this fatal malady. An interesting fact, corroborative of the observation that arachnitis and consequent effusion into the cavities of the brain are especially apt to result from intestinal irritation, is- the circumstance that cholera in- fantum, when it assumes somewhat of a chronic form, terminates not unfrequently in death, under all the characteristic symptoms of the-last stage of hydrocephalus. In two instances of this kind, in which I had an opportunity of a post-mortem examination, I found the traces of arachnoid inflammation unequivocal, with copious serous effusion into the ventricles, and between the circumvolutions of the brain.* While we give all the importance to intestinal irritation, as a cause of arachnoid inflammation, which it unquestionably demands, we must bear in mind, that this same cause sometimes gives rise to a form of cerebral oppression, strongly resembling the last stage of arachnitis, but which is, nevertheless, wholly unconnected with cephalic inflammation. The determination to the head* in such cases, results merely in a state of strong venous congestion of the brain, giving rise to a somnolent and oppressed state of the system, which may be readily mistaken for hydrocephalus. (Cheyne.)t Treatment.—There are three principal indications to be kept in view in the treatment of arachnoid inflammation—viz.: 1, to mode- rate the general arterial action ; 2, to obviate the local congestion and inflammatory action in the brain; and 3, to remove those causes of irritation which tend to keep up a preternatural determination of the blood to the head. When the disease becomes the object of medical attention in its early and incipient stage, the chief indication is to obviate local and general irritation, and to prevent undue determination of the blood to the head. With this view, the attention is to be particularly di- rected to the alimentary canal, for it is here that the primary irrita- * An interesting and striking case, in which hydrocephalic symptoms were produced by organic disease of the intestinal canal, is related in the Med. and Chir. Rev., July, 1826, p. 102. t Some writers contend, that hydrocephalus is almost invariably a sympathetic affection. Dr. Yeates, in particular, thinks that this disease has almost invariably its origin in the irritation of some organ remote from the brain, (a) Spurzheim admits that the primary irritation is frequently located in the abdomen; "yet anatomical dissections have convinced me," he says, " that, in the greater number of cases, the morbid appearances of the abdomen are secondary of the cerebral disease." (a) Letter to Dr. Wall, &c.—Med. Chir. Journal, Jan., 1819. INFLAMMATION OF THE BRAIN. 291 tion and immediate cause of cephalic congestion most commonly exist. Laxatives are accordingly among our' most valuable means for preventing the full development of the disease whilst it is yet in its incipient stage; and this is more especially the cage in those in- stances which are attended with well-marked signs of intestinal dis- order. As the liver is usually inactive, or functionally deranged, in the commencement of the disease, calomel, in small doses, succeeded by small portions of some of the milder purgatives, constitutes a very appropriate aperient in this affection. From one to two grains of this preparation should be given in the evening, followed next morn- ing with a weak dose of Epsom salts, or of powdered rhubarb, for a child of from one to five years old. In some instances of impending arachnitis, with manifest intestinal and hepatic derangement in chil- dren, I have derived much benefit by giving a grain of blue pill every evening, followed by a few drachms of castor oil in the morn- ing. The aperient and mercurial remedies should be continued daily until the alvine discharges exhibit a natural appearance. In addition to these means, the greatest attention must be given to the dietetic management of the patient; for without an appropriate diet, little or no advantage can be derived from remedial treatment of this affec- tion. The most simple and unirrifating articles of food alone must be allowed, such as boiled milk, barley-water, arrow-root, boiled rice, oat-meal gruel, weak beef or chicken tea, &c> When the arachnoid inflammation is once fully established, the plan of treatment should be promptly and decisively antiphlogistic, with revulsive and derivative application. Blood-letting ranks of course among our most efficient remedial means at this period of the disease, particularly when the inflammation is the consequence of some injury inflicted on the head, or where it results from gene- ral causes, such as cold. In such instances, the pulse is tense, quick, resisting and sharp; and in this case, the efficient abstraction of blood is indispensable. In those cases which arise sympathetically from disorder in the alimentary canal, the arterial excitement is not gene- rally very active. Here blood-letting, though usually indicated, must be employed with more caution, for it is well ascertained that the copious abstraction of blood, by weakening the powers of vital re- sistance, greatly favours the morbid sympathetic affections arising from intestinal irritation —(Armstrong, Marshall Hall, Travers.) In all instances, however, where the pulse indicates blood-letting, a suf- ficient quantity of blood should be taken away at once, to check, conspicuously, the activity and momentum of the circulation. After the symptoms of cerebral compression have ensued, sanguineous eva- cuations can be of little or no service ; nevertheless, should the arte- rial excitement and cephalic congestion be considerable, blood should be abstracted even in this advanced stage of the disease. With regard to the utility of local bleeding in this and other forms of encephalic inflammation, different opinions are expressed by prac- titioners. Nearly all the French writers on this disease are decidedly in favour of the local abstraction of blood. It appears, indeed, very reasonable to expect peculiar advantages from a mode of depletion 292 INFLAMMATION OF THE BRAIN. which abstracts the blood more immediately from the affected parts; and yet, in relation to the present disease, a contrary opinion has been expressed by several eminent practitioners. Mr. North, in his work on the convulsive affections of infants, observes, " that he never found well-marked symptoms of determination to the head removed by leeches, however freely they were applied." In cases in which the cephalic determination depends on intestinal irritation, this obser- vation is no doubt well founded ; for the blood which may be thus removed from the capillaries of the head, will be immediately re- placed by the continued -preternatural afflux of this fluid. It must be observed, moreover, that so long as the momentum of the general circulation is considerable, local bleeding can scarcely produce any other advantages than such as would result from abstracting the same quantity of blood by means of the lancet. General and adequate bleeding is, therefore, an essential preliminary to the beneficial em- ployment of leeches or cupping. After the impetus of the circulation has been moderated by the use of the lancet, leeching the temples, and along the posterior parts of the ears, is a valuable auxiliary in the treatment of arachnitis. Cupping is, perhaps, preferable to leech- ing in adults, for this operation seems to be better calculated to derive the circulation from internal inflamed parts than leeches. Purgatives are among our most useful means for subduing this disease. When the bowels are loaded with irritating substances, and the cerebral affection is symptomatic of intestinal irritation, laxatives are, in truth, the main stay of our hopes. They are, indeed, almost equally useful in idiopathic arachnitis; for, besides their effect in evacuating irritating causes, they tend, very particularly, to diminish the afflux of blood to the brain, and to moderate the general momen- tum of the circulation. In cases depending on a primary irritation of the alimentary canal, the milder laxatives, after the first thorough evacuation of the bowels by an active purge, should be employed in such a way as to keep the bowels in a relaxed state throughout the whole course of the disease. Repeated doses of the more active purges, though, at first, apparently useful in such cases, tend ulti- mately to increase the intestinal irritation, and consequently the ce- phalic affection. The first purge should be sufficiently active to eva- cuate the bowels well. Four or five grains of calomel, followed in a few hours by the occasional use of the infusion of senna and manna until free purging is produced, will answer well as a first purgative. The bowels must afterwards be regularly evacuated three or four times daily, by the use of small doses of calomel, promoted by castor oil and laxative enemata. It must be recollected that intestinal irri- tation is not always dependent solely on the presence of acrid or irri- tating matters in the bowels. The mucous membrane of the alimen- tary canal may be in a state of subacute inflammation, with more or less of abrasion, or perhaps ulceration. Under these circumstances, the milder laxatives are manifestly more appropriate than the more irritating articles of this class, since they are sufficient to evacuate the contents of the bowels, without causing, injurious irritation. In idio- pathic arachnitis, however, the bowels are almost always very torpid, INFLAMMATION OF THE BRAIN. 293 and can seldom be adequately moved, without the employment of the more active purgative remedies. In cases, too, that are attended with a great accumulation of fecal matter in the bowels, brisk and frequent purgation is particularly necessary. " Should we ascertain," says Dr. Cheyne, "that the alimentary canal is torpid, and imperfectly per- forming its functions, and admitting an accumulation of fecal matter, or that the secretions flowing into it are vitiated or diminished in quantity—circumstances which we ascertain by the peculiarity in the appearance or the pungent fetor of the stools, we must, by steadily pursuing the purgative plan, endeavour to affect a change ; for while this is produced in the appearance of the stools, we are affecting a more important change in the hepatic system of the alimentary canal, and of all the parts which are connected with them." Calomel should enter largely into the purgatives employed in this disease. From one to three grains, according to the age of the patient, may be given every two or three hours, until from ten to twelve grains are administered, and followed by a dose of infusion of senna, or sulphate of magnesia, or castor oil. In cases where there is reason to suspect the presence of worms in the bowels, anthelmintics should be employed in conjunction with purgatives. An infusion of spigelia, and senna may be used in such instances. The stomach, however, is often so extremely irritable in this disease, that no articles will be retained a sufficient time to operate on the bowels. Where this state exists, we must endeavour, in the first place, to allay the gastric irri- tability, and this may, in general, be effected by minute doses of calo- mel and ipecacuanha: the one-sixth of a grain of the former, in union with one-fourth or one-third of a grain of the latter, has repeatedly succeeded in my hands to restrain the tendency to vomiting in this disease. Mercury has been much recommended as a remedy in this affec- tion. One of the only two cases of recovery from apparently com- pletely developed arachnitis, which have occurred in my practice, appear to have been brought about by the mercurial influences. Drs. Percival, Dobson, Rush and Cheyne, mention cases which yielded to the powers of this article. Employed with a view to its constitu- tional influence, mercury often contributes very decisively to the re- duction of visceral inflammation, and experience has shown, that in the present affection, its powers are sometimes unequivocally bene- ficial. The best mode, perhaps, of employing mercury in this disease, with a view to its salivant operation, is in the form of friction with the ungt. hydrar. In whatever way mercurials are used, it is always extremely difficult in children to procure its salivant effects. Almost the whole surface, should be frequently rubbed with the mercurial ointment, where this effect is desired. Nothing is more common in the treatment of this disease than the application of blisters to the shaven scalp ; but this practice is, I con- ceive, of very doubtful propriety. I have always preferred placing them on the back of the neck or behind the ears, while ice or cold water is applied to the top of the head, and warm or rubefacient applications made to the feet. Dr. North, whose interesting work I 294 INFLAMMATION OF THE BRAIN. have already mentioned, observes, «that blisters to the head are decidedly prejudicial in the convulsive diseases of infants ;" and the same observation is applicable, I think, to the disease under considera- tion. The application of ice or iced water, in the manner mentioned in the last chapter, may be accounted a very useful auxiliary in the treatment of arachnitis, and to favour its revulsive influence, warm or stimulating applications to the feet may be usefully employed. Dr. Regnault recommends, in very strong terms, the application of moxa in this complaint ;* and its known efficacy in subduing deep- seated articular inflammation, justifies the expectation of considera- ble advantage from its use in arachnoid inflammation. Neither this application nor blisters, however, should be resorted to, until the activity of the circulation is reduced by general and local blood-let- ting. The tartar emetic ointment, also, may be very beneficially applied. (Monro. )t Dr. Stocker,J of Dublin, speaks much in favour of the use of James's powder in hydrocephalic affections. He asserts that this preparation possesses peculiar powers to diminish the determination of the blood to the head; and of its tendency in this way, I have myself known several examples in other cephalic diseases. It may be conveniently given in small but frequent doses, in union with calomel, in this affection. Drs. Cheyne and Monro speak in equally favourable terms of this preparation in this dangerous disease. The latter states that he has cured several cases of this disease by a plas- ter composed of tartar emetic and wax ointment applied to the head, and the use of calomel combined with James's powder. This com- bination he says, is particularly useful in restoring the healthy action of the bowels. Dover's powder, also, has found advocates as a remedy in this disease. Drs. Brooke, Percival, Cheyne and Crampton,§ all speak favourably of this employment in hydrocephalus. After adequate depletion and purgation, in cases connected with intestinal irritation, small doses of this composition often prove serviceable, by allaying general irritability, and inducing a gentle diaphoresis In the idio- pathic form of the disease, however, opiates of every description must be carefully avoided, as their tendency to increase the flow of blood to the brain could hardly fail to prove injurious. When pre- ternatural determination to the head depends on a remote focus of irritation—as in the mucous membrane of the bowels—opiates, by diminishing nervous excitability as well as local irritation, will occa- sionally reduce also the irregular determinations which depend on such irritations. It is in cases of this kind only that we may venture on the exhibition of Dover's powder, and not in these instances until * Medical and Physical Journal, vol. xl. p. 16. t [In the last stage of arachnitis, I am confident that blisters over the scalp are most advantageous.—Mc] X Dublin Medical Essays, anno 1806. $ Transact, of the Associat. of Fellows and Licentiates of the Queen's Col- lege of Physic, in Ireland, vol. vii. INFLAMMATION OF THE BRAIN. 295 the impetus of the circulation has been moderated, and the alimen- tary canal well evacuated. It would seem, fromahe observations of Mr. Newnham, that green tea has a powerful tendency to lessen the morbid vascular action, not only of the system generally, but especially of the brain. " In the acute irritation of the membranes of the brain in children," he says, " the efficacy of green tea has been strongly marked in my practice. Exhibited during the early symptoms, as soon as a suffi- cient quantity of blood has been taken, and before effusion occurs, it has proved a more powerful means than any other we possess, of controlling the morbid^ action, which, if suffered to proceed to its second stage, is scarcely to be overtaken by any treatment."* Sect. III.—Of Cerebritis—Softening of the Brain. (Ramollissement du cerveau.) This form of cerebral disease has of late been particularly investi- gated by the French pathologists. Recamier, Bayle, Cayol, Briche- teau, Rostan, and Lallemand,t have published numerous and inte- resting observations concerning its symptoms and pathology. The disease, as it is manifested on dissection, consists of a softening or a kind of liquefaction of a portion of the cerebral mass, with vascular injection of the surrounding substance. Rostan divides the disease into two periods. The symptoms of the first period are: a fixed and violent pain in the head,often continued for several months; vertigo; obtuseness of the mental faculties; confusion of the ideas; and weakness and tem- porary loss of memory; questions are answered after long hesitation : and the patient appears at times dejected, querulous, and-wholly indifferent to surrounding objects. There is generally a sensation of tingling and numbness in the extremities of the fingers; vision is often perverted, and in some instances, total blindness occurs at times. The hearing is almost always dull, but in some cases the reverse obtains, the sense of hearing being morbidly acute. Some complain of tenderness of the epigastrium, with constipation and variable appetite. The pulse is often full and hard, and sometimes intermitting. Occasionally, there is ternporary delirium, with fever and much agitation. The second period is characterized by the gradual or sudden super- vention of paralysis of one limb, sometimes of half the body; but consciousness and intellect remain. Questions are now answered with very great difficulty, the patient generally expressing his desires by automatic movements. In some instances a complete state of coma occurs, followed occasionally with convulsions. In most instances, a sudden attack of convulsions is the first symp- * Med. Chir. Rev., July, 1827. t Recherches Anatomies Pathologiques sur l'Encephalite. Paris, 1820. 296 INFLAMMATION OF THE BRAIN. torn that excites alarm. These convulsions often continue for many hours, followed, in some cases, with deep coma and a contracted state of the flexor muscles of the limbs. Occasionally, the parox- ysms of convulsions recur repeatedly at short intervals, " the patient being sensible in the intermediate periods, and complaining of head- ache, till after twelve or twenty-four hours, coma supervenes. From this state there is often a complete recovery for several days, when, without any warning, the convulsions return, and end in fatal coma." In a case which came under my care, the patient complained at times of a deep-seated pain in the head; his memory for particular names and things was greatly weakened—so much so that he forgot the name of the street he lived in; and was several times obliged to inquire the way to his own house, although but a square from it. He became taciturn, and uttered his words with a kind of hesitating doubt. He continued in this condition for five or six weeks before he was confined to his room. The pain, however, at length became very severe; the pulse was very hard and strong; the countenance flushed; and the bowels costive ; but there was no delirium, and he experienced short intervals of perfect ease from the cephalic pain. After five or six days longer, double vision, great confusion of mind, and hesitancy of speech occurred, and at last deep coma, contraction of the extensor muscles of the forearms, convulsions, and death ensued. In this instance, the membranes of the brain did not exhibit any morbid appearances, except much vascular congestion. On slicing away the superior part of the brain, it appeared to be in a perfectly natural state; on making a deeper section, however, three portions of the cerebral substance were discovered in a state of complete disorganization—being of a soft pap-like consistence, of a yellow- ish colour, and in one place of a darkish hue, as if dissolved blood had been mixed up with the softened portions of the brain. One of these disorganized portions was in the left posterior lobe of the cerebrum, and the other two near the corpora striata and thalami opticorum.* * [I made this post-mortem examination, and attended the patient in consulta- tion with the late Drs. Eberle and Parrish. It is stated correctly, with the omis- sion, however, that the cerebral substance was everywhere studded with red puncta under the knife, and exhibited the most decisive signs of long-continued vascular engorgement. My son and Dr. Leidy have this very day examined the body of a patient whom Dr. Bacon and I attended for some weeks before death, under nearly the same symptoms. The left side had become totally paralyzed during the last two or three days, and the ramollissementwas found to be located in the right crus cerebri, and in the external portion of the adjacent thalamus opticus. The whole medullary substance of both hemispheres was of a dark or dusky hue, and studded with numerous and large bleeding puncta throughout. The pia mater was everywhere deeply loaded with blood, and the arachnoid in the fourth ventricle very much thickened and opaque. Indeed, I have never seen a case of ramollissement that did not exhibit all the signs of vascular engorge- ment and cerebral inflammation.—Me.] INFLAMMATION OF THE BRAIN. 297 The inflammatory nature of this softening of the brain has been much doubted by some. It has been supposed to be the consequence of a process similar to that which occurs in the softening of tubercu- lous matter in the lungs, and which, according to Laennec and some other writers, is sui generis, and wholly independent of inflamma- tion. The facts and arguments adduced by Lallemand, however, render the opinion of its inflammatory character, in most instances, at least, extremely probable. The writer thinks that the softening is the " effect of inflammation arrested in its course by death, before purulent suppuration has had time to take place." It is most probable, as Dr. Abercrombie* observes, that this affec- tion occurs under two modifications, one unequivocally attended with cerebral inflammation, and the other a species of cerebral gangrene from defect of circulation, in consequence of a diseased state of the arteries of the brain—an opinion which, he thinks, is confirmed by the fact, that the peculiar softening of the brain mentioned by Ros- tan, as unconnected with symptoms indicating an inflammatory ac- tion, occurs almost exclusively in very aged individuals, inasmuch as ossification of the cerebral arteries is very common in elderly people. " In the cases of Rostan," says Dr. Abercrombie, " the disorgani- zation was observed chiefly in the external parts of the brain; it occurred almost entirely in very old people, few of his cases being under sixty years of age, many of them seventy, seventy-five, and eighty. It was found in connection with attacks of a paralytic or apoplectic kind; many of them protracted; and was often found combined with extravasation of blood, or surrounding old apoplectic cysts. On the contrary, the affection which I had been anxious to investigate, was found chiefly in the dense central parts of the brain, the fornix, septum lucidum, and corpus callosum, or in the cerebral matter immediately surrounding the ventricles ; and occurred in per- sons of various ages, but chiefly in young people and in children. It took place in connection with attacks of an acute character, chiefly of the character of acute hydrocephalus; and it was in many cases distinctly combined with appearances of an inflammatory character, such as deep redness of the cerebral matter surrounding it, suppura- tion bordering upon it, and deposition of false membrane in the membranous parts most nearly connected with it. We may even observe in different parts of the same diseased mass, one part in the state of ramollissement or softening, another forming an abscess, while a third retains characters of active inflammation, and probably exhibits, as we trace it from one extremity to the other, the inflamed state passing gradually into a state of softening. This is the infec- tion which 1 have endeavoured to investigate, and which I consider as one of primary importance in the pathology of acute affections of the brain, and which I cannot hesitate to consider as the result of inflammation." * Pathological and Practical Researches on the Diseases of the Brain, &c. By John Abercrombie, M. D. London, 1827. 298 PNEUMONIA. One of the most characteristic phenomena of softening of the brain, is a rigid contraction of the flexor muscles of the limbs. " Sometimes," says Lallemand, " this amounted only to simple rigidity of the limbs ; at others, it was carried so far that the patient's fist was kept rigidly applied to the shoulder and the heel to the buttock ;" and, contrary to what takes place in apoplexy, the mouth is drawn towards the paralyzed side. In general, the function of respiration remains en- tirely free from disorder, till within a few days of the fatal conclusion of the disease. The exciting causes of this form of cerebral disease are, no doubt, very various. Aneurism of the heart appears to be capable of exciting the disease. In many cases, says Lallemand, suppression of some habitual sanguineous evacuation preceded the attack of this affection ; the depressing mental emotions seemed, in some instances, to have favoured its occurrence; and " many of the victims had been greatly addicted to the immoderate use of vinous and other fermented liquors." Dr. Johnson states that he has seen several cases which induce him to believe that " venous congestion of the meninges of the brain has a very considerable effect in producing softening of the brain as well as sudden death."* I have seen a case of a pap-like and yellowish- brown disorganization of an internal portion of the brain, which occurred in consequence of a severe blow received on the head six months before the supervention of the disease. Treatment.—General and local blood-letting; sinapisms to the feet; cold applications to the head; active cathartics; blisters to the back of the neck; and calomel, with a view of its salivant operation, constitute the efficient means for combatting this formidable malady. Unfortunately, however, the disease often proceeds to a state of dis- organization before it becomes the object of medical attention, and then, of course, all remedial treatment must be abortive. CHAPTER XII. OF THE PHLEGMASIA OF THE RESPIRATORY ORGANS. Sect. I.—Pneumonia. The term pneumonia is employed, in a general sense, to designate acute inflammation within the cavity of the thorax, whether seated in the pleura, the mucous membrane of the bronchia, or in the pro- per substance of the lungs. The general characteristic symptoms of acute inflammation in the chest are:—cough, difficult and painful respiration, fixed pain in the thorax, and fever. Considerable difler- * Medico-Chirurgical Review, December, 1822, p. 485. PNEUMONIA. 299 ence occurs, however, in the character of these symptoms, as well as in the other usual concomitant phenomena, according as the one or the other of these three structures just named is the principal or exclusive seat of the inflammation. Cullen was of opinion that the pleura can never be inflamed without an extension of the inflamma- tion to the pulmonary structure; pleuritis, according to his views, being always accompanied with more or less of peripneumonic inflam- mation. The observations of later pathologists,* however, have proved that the pleura is often exclusively inflamed, and that pleu- ritic inflammation is generally marked by symptoms sufficiently cha- racteristic to enable us to distinguish it from acute inflammation of the proper pulmonary substance. Without doubt pleuritis is very generally attended with inflammation of the subjacent tissues; but its occasional separate existence is equally unquestionable. Pleuritis.—Pie u risy. In pleuritis, a violent and pungent pain is felt in the chest, gene- rally on one side, which is always greatly increased by a full inspi- ration, or on coughing. Respiration is hurried, short, and generally most oppressed when the patient lies on the affected side. The cough is short and dry, or attended with a glairy and nearly colourless sputa, and stifled as much as possible, to avoid the great increase of pain which it occasions. When the inflammation extends to the lungs, the expectoration is generally mixed with more or less of blood. The face is usually suffused with a vivid flush ; the pulse very hard, full, vigorous and frequent; the tongue covered with a thick, white fur; the skin hot and dry ; and the urine of a deep red colour, and small in quantity. The act of respiration is performed chiefly by the action of the diaphragm and abdominal muscles, the motion of the ribs being restrained by the patient, on account of the increase of pain which it always causes. Acute inflammation of the pleura is, however, not always attended by the foregoing unequivocal manifestations of its presence. In some instances, the disease, though rapid in its course and violent, is at- tended with scarcely any pain or cough. Baglivi mentions examples of this kind ; and Schmidtmann has given the history of several cases of what he calls pleuritis occultaA" Mr. Tacheron gives an account of a fatal case, in which there was but little pain, and no cough, although the pleura was found, on dissection, coated with a yellow albuminous matter, a line in thickness, and a large quantity of fluid effused into the thorax.J Bichat also refers to the circumstance of the occasional absence of pain in the chest in acute inflammation of the pleura. * Laennec. t Summa Obs. Med., vol. i. p. 108.. X Recherches Anatomies Pathologiques, &c.—Vide Med. Chir. Rev., March, 1824. 300 PNEUMONIA. Causes.—Pleuritis is most apt to attack persons of a vigorous and plethoric habit of body. The influence of cold, when the body is in a state of perspiration from active exercise or confinement in a heated room, is its most common exciting cause. Pleurisy may also arise from metastasis of other affections—particularly of rheumatism, gout, and erysipelas; and it has been known to occur in consequence of suppression of the catamenial and hemorrhoidal discharges. Pleurisy from translated rheumatism or gout, is by no means an uncommon occurrence. I have met with a considerable number of cases of this kind, and one recently which was a strongly-marked in- stance. The patient was affected for several weeks with severe rheu- matic inflammation of the left elbow joint. A cold poultice was ap- plied to the joint in the evening, and on the next morning the pain and redness had in a great measure subsided. In the afternoon, a severe pain came on in the left side of the thorax, which rapidly increased in violence, and soon exhibited all the characteristic phenomena of pleurisy, whilst the pain in the elbow disappeared entirely. It was successfully treated with blood-letting, blisters, and the internal use of calomel and opium. In a few weeks after recovering from this attack, subacute rheumatic inflammation occurred in the elbow of the right side.* Pleurisy and depots of pus in the lungs are sometimes rapidly developed after capital surgical operations. M. Velpeau, in a very interesting memoir, has given the following as the result of his ob- servations on this subject: 1. " Those who die of acute diseases suc- ceeding surgical operations or profuse suppurations, generally fall victims to pleurisy, and the formation of abscesses more or less numerous in the lungs. 2. That the kind of pleurisy hitherto unde- scribed is of a peculiar nature, and might be denominated the pleu- risy succeeding surgical operations. 3. That this disease differs from simple pleurisy in the latency of its progress, the rapidity of its course, and the almost invariable certainty of its fatality. 4. That the pleurisy and formation of depots of matter are rarely accompa- nied by characteristic local symptoms sufficient to give notice of their existence." M. Velpeau ascribes these secondary pneumonic affec- tions to the absorption of pus, and its passage into the current of the circulation.t Post-mortem appearances.—On dissection, the pleura is generally found uniformly red, or punctuated with small red specks of irregular shape and very close together. Laennec states that these red points " occupy the whole thickness of the pleura, leaving small intermediate spaces retaining the natural white colour." The pleura is not often found thickened in consequence of inflammation. Extravasation on the inner surface of this membrane is a never-failing occurrence in fatal cases of this disease. Laennec thinks that this extravasation * For much interesting information concerning rheumatic pneumonia, the reader is referred to Stoll's Ratio Medendi, &c. part i, p. 82—and to Schmidtmann's Sum- ma Observ. Medicarum, torn, i, p. 62, et seq, t Revue Medicale, December, 1826. PNEUMONIA. 301 commences with the inflammation. The matter thus thrown out by the vessels of the inflamed pleura, consists of a semi-concrete or pseudo-membranous substance, or of coagulable lymph, or of sero- purulent fluid effused into the cavity of the chest. This fluid generally contains small flocculi or filaments of coagulable lymph, or of con- crete pus, and is either of a light yellow colour and nearly transparent, or reddish, as if a small portion of blood were mixed with it. Ad- hesions between the costal and pulmonary portions of the pleura occur in nearly all instances through the intervention of false mem- branous substances.* Prognosis.—Acute pleuritis is not, in general, a very dangerous affection-in subjects of a good and vigorous constitution. There is no inflammatory affection which is more under the control of an active antiphlogistic treatment. In subjects, however, of a weak habit of body—and especially in such as are predisposed to phthisis pulmo- nalis—pleurisy, if not a disease of much immediate danger, is to be dreaded on account of its tendency to develop pulmonary consump- tion. When the inflammation extends to the substance of the lungs, the patient may sink at an early period from effusion into, or disor- ganization of its structure. The following circumstances may be regarded as indicative of imminent danger in this affection. A frequent effort to sit up, particularly when there is a wheezing sound in the trachea, bloody expectoration,! and an obstructed pulse. The super- vention of diarrhoea is a most unfavourable sign; convulsions and coma are no less ominous of a fatal tendency. Schmidtmann asserts, that he has never known an instance of recovery from this disease, after convulsions and coma had supervened. * The false membranes produced in pleurisy generally change after some time into a kind of cellular tissue, " or rather into a true serous membrane, like that of the pleura. This change," says Laennec, " is produced in the following man- ner: the serous effusion which accompanied the membranous exudation is absorbed; the compressed lung expands, and the false membrane investing it and the costal pleura become united in one substance. By degrees, this substance becomes divided into layers pretty thick and opaque, which are separated by a very small portion of serosity. About this time the blood-vessels begin to make their appear- ance in it, the first rudiments of which have the aspect of irregular lines of blood, much larger than the vessels which are to take their place. After a time the pseudo-membranous layers become thinner and less opaque: the lines of blood assume a cylindrical shape, and ramify in the manner of blood-vessels. Eventu- ally the layers of the false membrane become quite transparent, and nearly as thin as those of the ordinary cellular tissue. By degrees, it acquires the firmness of the natural cellular substance, and becomes the bond of a firm union between the lungs and the costal pleura." t Baglivi says, " Erectum sedere velle in morbis acutis pulmonum perniciosum ac ferme lethale, prsesertim. si adsit sibillus in aspera arteria, et difficultas excre- andi sputi, et licit cum talibus signis pulsum bonum videris, noli credere, nos fallit." Opera Omnia, p. 42. 302 PNEUMONIA BILIOSA. Pneumonia.—Inflammation of the Lungs. When the parenchymatous substance of the lungs is the principal or sole seat of the inflammation, the disease is designated by the term peripneumony. In this variety of thoracic inflammation, the breathing is much oppressed, particularly when the patient is in a horizontal posture; an obtuse pain is felt in the chest, generally in the region of the sternum, sometimes in the epigastrium, and occa- sionally in the side or scapular region. The cough is attended with a copious viscid expectoration, mixed more or less with blood. The skin is hot and dry; the urine high coloured and scanty; and the pulse frequent, full, obstructed, labouring, but rarely very hard; but in the advanced stage of the disease, it usually becomes weak, soft, obstructed and irregular. In violent cases, tending to effusion or disorganization of the inflamed portion of the lungs, the countenance acquires a livid aspect, and the veins of the neck become turgid. The patient generally lies on the affected side, although, in some instances, the reverse position is preferred. " The sputa are white, slightly yellowish or greenish, somewhat diaphanous, and intermixed with bubbles of air. The tenacity of the matter expectorated is so great, that we may often reverse the vessel which contains it, and retain it in this position for a time without detaching it from its sides." Laennec regards this kind of sputa as pathognomic of this affection, "since it is the only one," he says, "that is found exclusively in it." In this, as in the former variety of pneumonic inflammation, the symptoms are sometimes so inconspicuous and equivocal in their character, that the true nature of the disease may remain doubtful, or be entirely mistaken, until fatal disorganization has occurred in the pulmonary structure. An instance of rapid fatal pneumonia is reported by Dr. Damiron, one of the physicians of the Hospital Vol de Grace, in which no pain whatever was complained of by the patient, nor did epigastric pressure produce any uneasiness. The breathing was difficult, the cough frequent, the expectoration ropy and copious. On dissection, three-fourths of the right lung was hepatized, and the left lung was black and crepitous.* M. Andral has related seventeen cases, in which one or more of the characteristic signs of the disease were absent. In several instances, there was neither pain nor cough.t Pneumonia Biliosa.—Bilious Pleurisy. There is a modification of pneumonia, which from the prominent symptoms of hepatic disorder which it exhibits along with the ordi- nary phenomena of pneumonic inflammation, has been termed bilious pneumonia. This variety of the disease occurs during cold and variable seasons, in districts abounding in sources of miasmatic ex- halations. It appears to be the result of the combined agency of * Med. Chir. Rev., October, 1825. t Clinique Medicale, &c. Par G. Andral. Paris, 1824. PNEUMONIA BILIOSA. 3Q3 koino-miasmata and atmospheric vicissitudes. The initial symp- toms of this modification of the disease differ very little from those which usually usher in an attack of ordinary bilious remittent fever. In some instances, a sense of fullness and' tension is experienced in the right hypochondrium, a few days previous to the supervention of the disease, and occasionally dysenteric symptoms occur before the fever commences. In almost all cases, considerable pain is felt in the back and extremities during the premonitory period. The skin from the beginning is more or less tinged with bile, and the conjunctiva, especially, is often conspicuously icterode. The face is flushed, "and a sickly mixture of red and yellow, upon close ex- amination, betrays the existence of a disturbed state of the liver." (Potter.) Acute pain in the forehead is almost constantly present. The pain in the chest is sometimes extremely severe and pungent; but more commonly it is obtuse, and attended with a sense of weight or oppression in the breast. In some cases the lever continues for several days before the pectoral pain supervenes. The expectoration is not very copious—the sputa being of a frothy yellowish appear- ance, marked frequently with streaks of blood. The fever is gene- rally attended with manifest evening exacerbations and morning remissions. When vomiting takes place, an occurrence very com- mon in this affection, more or less of bilious matter is generally thrown up, although, in some instances, the secretion of bile appears to be entirely suspended ; the ejections consisting of nothing else than gastric mucus and the ingesta. The tongue is at first white, with a yellowish streak along the middle, which, as the disease advances, becomes dark-brown and dry. The urine is always of a deep yel- low or bilious colour; and the pulse is generally small, frequent and quick, with a slight degree of preternatural tension. Post-mortem appearances.—The morbid structural changes pro- duced in the lungs by inflammation are : 1. Engorgement, the inflamed portion of the lungs exhibiting externally a brown mottled or violet colour, " which forms a strong contrast with the gray or pale rose-colour of the healthy part." It is of a firmer texture, and heavier than in the sound state—feels cre- pitus under the finger, though less so than in the healthy condition ; and on being pressed between the fingers, the air-cells will be per- ceived to contain a considerable portion of extravasated fluid. When the engorged portions of the lungs are laid open with the knife, a large quantity of a frothy reddish serosity runs out, and the internal structure exhibits a livid and red appearance. If portions of the engorged lung are pressed until all the fluid has been squeezed out, they become as elastic and crepitous, and of the same colour as the healthy part, if air be blown into them. Simple engorgement ap- pears to be the result of the weakest grade of acute inflammation, and may even arise mechanically from mere sanguineous congestion during the last moments of life, or in articulo mortis. (Andral.) When the inflammation is intense, and terminates in the above en- gorged condition, the structure of the lungs is at the same time ren- 304 PNEUMONIA BILIOSA. dered soft or friable,being readily broken down when pressed between the fingers. To distinguish mere engorgement by extravasated fluid from sanguineous congestion and engorgement from inflammation, we must judge less, says Andral, from the colour than the degree of firmness of the pulmonary structure. In almost every instance aris- ing from inflammation, the substance of the lungs is rendered more or less friable. 2. Hepatization, presenting at first sight the appearance and con- sistence of liver. In this variety of structural change, the lung is impermeable by air, and is entirely deprived of its crepitous feel under the finger, and sinks when put into water. When cut into, a small portion of a reddish fluid issues, without exhibiting any frothy appearance. If we examine the incised surface with a lens, we per- ceive that the lung has lost its cellular structure—the pulmonary sub- stance exhibiting a red granulated appearance; and on being pressed between the fingers, is found to be readily broken down and reduced to a reddish pulp. (Andral.) When a lung is hepatized, its volume seems much greater than natural, " but this apparent enlargement is caused merely by the diseased lung not collapsing." This morbid condition has been called red hepatization. 3. Gray hepatization.—This seems to be the result of a more intense degree of inflammation than that which gives rise to red hepatization. In the present morbid condition, the pulmonary struc- ture is granular, condensed, and impermeable to air, as in the preced- ing variety; but its colour is grayish or yellowish pale, and when cut into, discharges copiously an opaque-yellowish or grayish fluid, which is manifestly purulent, and almost entirely without smell. In some cases, the pus does not issue spontaneously from the incised sur- faces, but on pressing the tissue moderately, small drops of purulent fluid are forced out. In this variety of disorganization, the pulmo- nary tissue is softened, and readily converted into a grayish pulp by pressure between the fingers. Acute inflammation of the lungs never terminates in induration of its structure ; this termination is peculiar to chronic pulmonary inflammation. According to Andral, there are two varieties of induration, the red and gray. 4. Gangrene.—This is a very rare termination of acute inflamma- tion of the lungs. Andral gives an account of two instances of this kind. In a late number of the Journal Hebdomadaire, there are several cases reported, which terminated in gangrene of the pulmo- nary structure. These cases were attended with an intolerable fetid and gangrenous breath, particularly during the fits of coughing, and the matter expectorated was of a chocolate colour, and emitted a most offensive smell. On dissection, a considerable portion of the lung was found converted into a putrid mass, containing fragments of pul- monary texture, of a black or violet colour. The surrounding por- tions of lungs were infiltrated and partly hepatized. Dr. Chambers, also, has published some cases of gangrenous suppuration of the lungs, in which he refers particularly to the intolerable fetor of the breath as a diagnostic sign of this mode of termination. Andral PNEUMONIA BILIOSA. 305 states, that at first the expectoration is a greenish liquid, then dirty gray, at times reddish, and exhaling an extremely fetid smell.* The formation of abscess from pneumonic inflammation, is also a very rare occurrence. Both Laennec and Andral assert, that pulmo- nary abscess is among the most uncommon terminations of acute inflammation of the lungs. The former met with but four or five instances in several hundred cases which he examined ; and the latter writer states that he has met with one case only. Laennec observes, that " nothing is more uncommon than to find the inflammation confined to the superior lobes of the lung." This, however, is contradicted by the observations of Andral, who, in 88 cases, found 47 with inflammation of the inferior lobe, 30 of the superior lobe, and 11 instances in which the whole lung was affected. Diagnosis.—The most important diagnostic signs between pleurisy and peripneumony are those obtained by percussion of the chest, and by pressure made on the abdomen. In peripneumony, percussion made with the extremities of the fingers brought together in a line, produces an obscure dull sound, which is best estimated by compar- ing it with the sound produced by percussion of the healthy side of the chest. In pleurisy, on the contrary, no difference can be perceived in the sound produced by percussion of the two sides of the thorax. In peripneumony, firm pressure on the abdomen with both hands, so as to push up the diaphragm against the lungs, almost invariably excites cough, great oppression, and a sense of suffocation ; whereas, in pleurisy, no such effects result from abdominal pressure. " If, then, we find united in the same patient a clear sound of the painful side on percussion ; insensibility to abdominal pressure ; smallness and rapidity of the respiration ; an increase of pain on full inspiration ; particular uneasiness upon lying on the affected side ;t and, lastly, pain upon firm pressure of the intercostal spaces of the affected side, we have little reason to doubt of the existence of pleuritic inflammation." (Roux.) Peripneumony is characterized by an obscure pain in the chest; great efforts at inspiration, in order to supply the suspended functions on one part of the lungs ; increased suffering on firm abdominal pres- sure, and a dull obscure sound on percussion of the chest. Difficulty of lying on the sound side is generally mentioned among the charac- teristic symptoms of peripneumony; but Andral asserts, that this observation is by no means generally correct. The most common position is on the back. Auscultation, or the employment of the stethoscope, has of late years attracted much attention, as a means for obtaining a correct * Schmidtmann, in an account of a case of pneumonia which terminated in gangrene of the lungs, says, " impar sputes saniosis, fuscis, nigris, putentibusque reddendis."—Sum. Ob. Med., vol. i. p. 80. Cases of gangrene of the lungs are also reported by MM. Martinet and Reca- mier in their Hospital Reports.—See Revue Medicale, for 1827. t This arises from the lungs pressing on the inflamed pleura when the patient lies on the affected side. vol. I.—20 306 PNEUMONIA BILIOSA. diagnosis in pectoral diseases. Interesting information with respect to the particular condition of thoracic affections, is no doubt to be obtained from this mode of examination; but it requires much care- ful experience before a sufficient tact is acquired to procure satisfactory information in this way. M. Andral, who has paid much attention to this subject, has given the following account of his experience in auscultation in pneumonic inflammation. " No sooner does the pain and difficulty of breathing come on, than the ear, applied to the thoracic parietes, recognizes a notable modifica- tion in the nature of the noise heard at each inspiration, and as the inflammation advances,the noise undergoes fresh modifications, which indicate, with more or less precision, the situation and degree of the affection. The voice is also modified. " At the commencement of the disease, whilst the lung is in the state of simple inflammatory engorgement, the noise of respiration in the affected part loses its clearness, and is more or less mixed with the dry-rattle, which Laennec terms crepilous, from the resemblance it bears to the noise emitted by common salt when thrown upon hot coals. It also bears considerable resemblance to the peculiar noise occasioned by folding or doubling a piece of parchment. The noise of natural respiration is always altered and obscured by this rattle, but is not always entirely masked or concealed by it. As the inflam- mation increases, the rattle becomes more and more manifest, until at length it entirely conceals the inspiratory murmur. The presence of crepitous rattle indicates engorgement, or the first stage of inflamma- tion ; and-so long as it continues, it shows that the inflammation (in a great part at least), has not advanced beyond the fin>t degree. From its greater or less intensity, and from its more or less strong admixture with the natural respiration, we may derive indications of the degree to which the engorgement extends, and whether it is passing into the state of hepatization or otherwise. Whilst the noise of natural re- spiration predominates over the crepitous rattle, we may conclude that the inflammation is slight; but, if the rattle increases, and predomi- nates in its turn, until at length it completely masks the respiration, we may be certain that the inflammation is advancing, and that it is passing on to the second degree. " At a more advanced period, the crepitous rattle gradually ceases to be heard; and if the natural respiration then returns, we know the disease is subsiding; but if there be no respiratory murmur audible, or if the natural respiration is replaced by another kind hereafter to be described, we may be certain that the disease is becoming more serious, and that the lung is hepatized. " M. Laennec has established the fact, that, in many cases, when engorgement of the lungs is succeeded by hepatization, the ear applied to the chest feels the motion of the'thoracic parietes, but does not hear any respiratory noise, either natural or pathologic. We have often verified this statement; but we have also frequently observed, in the same stage of the disease, another very remarkable phenomenon, which appears to have escaped Laennec's attention. In certain cases, where the lung is in the state of red or gray hepatization, the noise of PNEUMONIA BILIOSA. 307 respiration does not disappear, but is modified in a singular manner, and is evidently different from the natural kind. It seems as if a per- son placed near the auscultatory ear breathed forcibly through a brazen tube; there is at the same time a peculiar kind of resonance of the voice, wherever this kind of respiration is audible. The modi- fication of the voice is not properly either egophony or pectorilo- quisrn ; it approaches more nearly to that form of resonance which is observed in dilatation of the bronchia. Whenever cases presenting this double modification of the voice and respiration have proved fatal, dissection has constantly presented either red or gray hepatiza- tion, or pleuritic effusion. '•The explanation of this modification of the voice and respiration seems easy. It appears to us to depend upon the air not being able to penetrate farther than the large bronchial tubes; and, for this reason, the phenomena are manifested,' not only in pulmonary hepa- tization, but also where the lung is compressed by pleuritic effusion : and, in short, wherever the air is prevented reaching the air-cells of the lungs. "Whilst auscultation of the diseased side affords the different signs already enumerated, the respiration of the healthy side is heard with much greater intensity than in the physiological state;—as if it were necessary for the healthy lung to receive a greater quantity of air in a given time, in order to supply the deficiency of the diseased one. " When the inflammation occupies a circumscribed portion situ- ated at a distance from the surface of the lung, more especially a part of the base of the centre or of the root, auscultation teaches us no- thing concerning the seat or degree of the disease."* Prognosis.—A copious expectoration of a thick uniform yellow- ish matter is one of the first, and perhaps most encouraging indica- tions of a favourable turn of the disease. When this symptom occurs in connection with an increased flow of sedimentous urine, and gentle diaphoresis, we have good grounds for predicting a favoura- ble issue of the disease, more especially, if at the same time the oppression and pain in the chest abate, and the cough is less trouble- some. When, on the contrary, the pain and oppression become more generally diffused throughout the thorax; when the cough is dry, or attended with dark or red liquid sputa; when, along with a sense of suffocation and great anxiety, the countenance and lips be- come livid, and the pulse soft, irregular, and labouring; and, finally, when delirium, coma, or convulsions supervene, or a sense of cold- ness is felt in the interior of the body, whilst the surface is very warm, the danger is to be considered as very great. A rattling respiration, accompanied with lividity of the countenance, and a constant effort by the patient, to bare the breast and to raise his head and shoulders from the bed, are almost certainly fatal indications.! The supervention of diarrhoea, in this disease, is a very unfavourable circumstance.! The prognosis in pneumonia is nevertheless at- * Med. Chir. Rev., October, 1826, p. 514. t Richter, Specielle Therapie, band, i., p. 415. Baglivi Opera., p. 42. X Baglivi Opera., p. 35. Riverius, Praxis Medica, t. i., p. 72. 308 PNEUMONIA BILIOSA. tended with considerable uncertainty. Instances of unexpected recovery occur, after the most dangerous symptoms have made their appearance; and, on the other hand, death sometimes speedily su- pervenes, in cases apparently free from particular danger. Treatment.—Both in pleuritic and peripneumonic inflammation, bleeding is the first and most important remedial means. The extent to which it is to be carried must be entirely regulated by the degree and obstinacy of the pain, and the state of the pulse. In pleurisy, we are generally obliged to abstract more blood than in peripneumonia, before the arterial reaction is sufficiently moderated. Whether the pleura or the proper substance of the lungs be the seat of the inflammation, however, a sufficient quantity of blood should be drawn at once, to make a very manifest impression on the pulse. The blood should be suffered to flow without any regard to mere quantity, until a diminution of the pain and oppression in the chest, as well as of the action of the pulse, ensues. If the action of the pulse and the pain increase again, more blood must be drawn, and again to the extent of producing a decided impression on the system. The blood should be drawn in a full stream from a large orifice. In pleurisy it is sometimes necessary to repeat the venesection three or four times in the course of the first twenty-four hours, before the violence of the disease is broken down. More ?caution, however, is necessary in the employment of the lancet in peripneumonic inflam- mation. Here, although prompt and very efficient blood-letting is decidedly beneficial, and without the least risk in the commencement of the disease, yet it is necessary to proceed with caution in the repe- tition of this measure, as the disease advances, lest dangerous pros- tration be induced. In violent attacks of peripneumony, the pulse is sometimes small, frequent, oppressed, and but slightly tense from the beginning of the disease. This state of the pulse may be owing to an oppressed or congested condition of the heart and large internal venous trunks; but it depends, also, occasionally, on an impaired state of the vital powers, particularly in what has been called nerv- ous or typhoid pneumonia. In such cases a vein should be opened; and if the pulse rises while the blood is flowing, we may proceed with confidence in the further abstraction of blood. Should the pulse become still weaker, however, the bleeding must be imme- diately stopped. Richter observes, that where the pulse is small in the commencement of peripneumonia, the physician should place his fingers on the artery, and request the patient to make two or three strong inspirations, or to excite him to cough, by causing him to inhale the fumes of vinegar. If, by these exertions, the pulse be- comes fuller and more active, we may be assured, he says, that there is still sufficient energy in the heart and arteries to justify the ab- * " Plus una vice vidi laeta morbi facie, et aegroto atque adstandibus sibi gratu- lantibus, ex pneumonia subito mortem accidisse. At non raro etiam contrarium observavi: rebus ferme conclamatis et aegroto ad stygis confinia posito, prudenti atque audaci medicatione cum e manibus libitinas evacisse.v—Schmidtmann, Ob. Med., t. i, p. 25. PNEUMONIA BILIOSA. 309 straction of blood.* The blood drawn in these affections exhibits a thick, sizy, or buffy coat, on the surface of a more or less cupped coagulum; and so long as the blood exhibits this appearance, bleed- ing may be regarded as a proper measure. The disappearance of the buffy coat is not, however, to be considered as a certain indica- tion that blood-letting is no longer proper; for where the action of the pulse and the degree of pain in the chest are such as to indicate the propriety of further abstractions of blood, bleeding may be con- fidently employed, notwithstanding the absence of the buffy coat on the drawn blood. " Some practitioners," says Dr. Millar, " have directed blood to be drawn, till the sizy crust which generally covers its surface, disappears. But this rule is extremely equivocal: in some the blood puts on this appearance at the beginning ; in others, not till towards the decline of the disease, and sometimes no crust is observed through the whole course of the disease. The only certain indication, therefore, arises from the mitigation or violence of the symptoms." Local bleeding by leeches seldom procures any particu- lar advantages in the early periods of these affections, beyond that which arises from its general depleting effects. AJter the disease has been in a great measure subdued, and venesection is no longer indi- cated, leeching may no doubt be occasionally beneficial. In this case, small and repeated doses of digitalis, also, sometimes contribute ma- terially to the further reduction of the general and local inflammatory action. A half a grain, in union with six or eight grains of nitre, may be given every three hours, until its effects on the pulse or stomach are manifested. Although gentle aperients are decidedly beneficial in pneumonic inflammation, yet general experience goes to show that active and repeated purging is much more apt to prove prejudicial than useful. This is more particularly apt to be the case after free expectoration has been established. Before the complete establishment of the ex- pectoration, Dr. Johnson states that he has known purgatives very beneficial in common pulmonic inflammation. Dr. O'Halloran also employed active purges with advantage in pneumonia, among the British troops at Gibraltar. (Med. Repos., No. 8 ) Nevertheless, as a general rule, active catharsis may be regarded as improper, unless, perhaps, in the very commencement of the disease. Small doses of one of the purgative neutral salts, or of castor oil, may be given, from time to time, so as to keep up a regular but moderate action of the bowels; or laxative enemata may be used with advantage for this purpose. Emetics are equally improper in pleurisy and in peripneumony; but in bilious pneumonia, they may be accounted as among our most useful curative means. Richter states, that in this variety of the disease, emetics will often remove the pain in the chest as by a charm; and Stoll makes the same observation. (Ration. Meden., t. i.) In the few cases of this modification of pneumonia in which I have prescribed, I have had the most satisfactory evidence of the * Specielle Therapie, band, i, p. 418. 310 PNEUMONIA BILIOSA. utility of emetics in its treatment. They generally bring on a uniform diaphoresis, promote expectoration, and allay the pain in the thorax, often almost immediately. They usually bring up an abundance of bilious fluid from the stomach. Cooling diaphoretics are very useful auxiliary remedies in these affections. Nitrate of potash with minute portions of antimony, the pulvis antimonialis, and the muriate of ammonia, are the best arti- cles of this kind in the present diseases. Richter particularly recom- mends the last-mentioned article in the treatment of inflammatory pectoral affections; and my own experience coincides entirely with his observations concerning its usefulness. It may be given accord- ing to the formula mentioned under the head of intermitting fever. With a view both of diminishing the action of the heart and arte- ries, and of promoting expectoration, nauseating doses of tartar emetic are generally highly useful. In Italy, large doses of this article are almost exclusively relied on in the treatment of pneumonic inflammation. Rassori and his followers make this the principal, and, in some instances, almost the sole remedy. They exhibit it to the extent of from a scruple to several drachms in twenty-four hours; and they assert that when given thus freely, it seldom excites either vomiting or strong purging, but always a most decided sedative or contra-stimulant impression on the sanguiferous system. M. Laennec speaks strongly in favour of large doses Of this antimonial in acute pulmonary affections. He asserts, that in cases treated solely by bleeding, the pulmonary engorgement, discoverable by the stetho- scope, continues much longer than in cases that are treated with large doses of tartar emetic. He thinks that, given to the extent of from twelve to twenty grains during the day, this article acts specifically in subduing inflammation, and powerfully promotes absorption.* Dr. Fontaneilles, of Milan,! whose experience confirms the observa- tions of Rasori on this subject, observes, that the power to sustain large doses of tartar emetic, depends wholly on the system being in a morbid condition; for in a healthy state, or after the disease is removed, the ability of taking large doses of this medicine without injurious consequences, does not exist. It would seem, moreover, that the power of bearing large doses of antimony in peripneumony, varies in the different stages of the disease. It is greatest at the acme of the disease—being less prominent in the beginning and in the decline of the inflammation. Dr. Fontaneilles generally gives about twelve grains per day in the first stage of the inflammation; but after the disease has advanced to its acme, from a scruple to half a drachm are administered in the same period. If the medicine pro- duce active vomiting, the dose must be diminished; but so long as the power of bearing it without great nausea or vomiting continues, the dose should not be lessened, although the symptoms of the dis- ease may be declining. Many practitioners have strongly recommended the employment * Revue Medicale, Mai, 1824.—Hospital Reports from La Charite. t Archives Generates, February, 1824. PNEUMONIA BILIOSA. 311 of calomel and opium in peripneumonic inflammation ; and my own experience has furnished me with repeated examples of the utility.of this practice.* After the disease has continued for three or four days, and the action of the heart and arteries has been duly mode- rated by depletion, opium often does much good by allaying the pain and cough, and powerfully promoting a salutary expectoration. There is nothing to be apprehended from its stimulating effects. When given in combination with minute doses of tartar emetic, or with calomel, after adequate abstractions of blood, this article has a more decided tendency to increase the expectoration and complete the resolution of the disease, than perhaps any other internal remedy we possess. When the pain and cough continue to be troublesome after venesection has been efficiently practised, a grain of opium in union with two grains of calomel, given every three or four hours, will seldom fail to bring great and permanent relief. Where, how- ever, the expectoration is free, and of a proper consistence, opium, if it be at all used, should be given in much smaller doses. One-fourth of a grain of this narcotic, with one-tenth of a grain of tartar emetic, or two or three grains of pulv. Doveri, may, under such circumstances, be given every four or five hours. In pneumonic inflammation from metastasis of rheumatism or gout, this article is especially beneficial. In sivch cases it ought to be given in large and frequent doses—two grains with the same quantity of calomel every two or three hours, until the system is completely under its influence. Richter states, that when pneumonia is the consequence of repelled cutaneous erup- tions, of measles, scarlatina, or of irregular gout, camphor, given in combination with ipecacuanha and opium, is, in general, a highly useful remedy. After blood has been decisively abstracted, one grain of camphor in union with the same quantity of opium and two grains of ipecacuanha, will often, he says, remove the pain and cough as by enchantment. If the pain returns, the dose must be repeated. Expectorants may be employed with advantage after the violence of the inflammation has been reduced by blood-letting; but the benefit to be derived from this class of remedies is, upon the whole, much less considerable than might be inferred from the known salu- tary influence of a free expectoration in this affection. In the early or active stage of the disease, all articles of this kind, with the ex- ception of tartar emetic, kermes mineral,} or mucilaginous fluids, * " Method! Hamiltoniana? commendatio ab illustri Sam. Gottl. Vogel, (a) cujus auctoritatem tanti semper feci, me movit earn tentare; et tentando edoctus sum ejus inventum et vulgationem magnum praxeos medieae esse incrementum. Prima pericula omnem longe superabant expeetationem raeam; quare viginti abhinc annis et ultra non facile morbus inflammatorios mihi obvenit—et multi centeni mihi obvenere—cui opium et calomel faustissimo cum successu non op- posuissem."—Schmidtmann, Sam. Obser. Medicar., t. i, p. 27. t R.—Kermes mineral, gr. xv. Extract, glycyrrh. gij. Aq. fontanae £vij. Syrup, scillac giij.—M. S, Take a tablespoonful every two hours. (a) Handbuch der Pract, Arzneywissenshaft, 4 ter. theil. s. 25, u. 231. 312 PNEUMONIA BILIOSA. are liable to do mischief. When the violence of the disease has been moderated, and the inflammation is about terminating in resolution, opium with tartar emetic, as has just been mentioned, will, in gene- ral, assist materially in establishing the expectoration. An infusion of the rad. poly gal, sweetened with honey, may be beneficially given during convalescence from pneumonic inflammation. The patient should be allowed the free use of demulcent drinks—such as barley- water, flaxseed-tea, or a solution of gum arabic, to which honey or currant jelly may be added. Blisters are among our most valuable means for subduing pneu- monic diseases. As soon as the firmness and activity of the pulse have been reduced, a large vesicatory should be applied over the region of the affected part. Baglivi observes, that in some instances of pleurisy, great difficulty of breathing and suppression of the ex- pectoration occur about the fifth or sixth day. In such cases, two blisters, he says, applied to the inside of the thighs, will generally produce a favourable change in all the symptoms. Triller recom- mends the same practice.* In protracted cases of pleuritic inflammation, where symptoms of effusion are present, a combination of calomel, digitalis, and squills, has been found particularly serviceable.! I have found the diuretic mentioned under the head of chronic peritonitis, very useful under circumstances of this kind. (See p. 25£.) In cases that terminate in empyema, paracentesis thoracis is recommended; and we are not without a considerable number of examples of the successful performance of this operation, both in empyema and vomica. Dr. Samuel Colhoun, in his edition of Gre- gory's Practice of Medicine, states, that " he has known a case in which this operation had the happiest effect, though the opening into the cavity of the abscess was deep, and penetrated far into the lungs."J For similar instances of successful paracentesis thoracis, * De Pleuritide, p. 48. t R.—Calomel 9i. Pulv. scillee 9ij. ----digitalis Q i. Conserv. rosar. q. s.—M. Divide into twenty pills. S. Take one three times daily. X [Dr. Colhoun alluded to an operation which I performed many years ago in his presence. The discharge was in that case decidedly purulent, consisting of more than 30 ounces of pure globular pus. As it was not like the serous contents of a distended pleura, we concluded that the case was one of interstitial pulmonary abscess; and that it militated against Laennec7s idea that such collections are always pleural. There was also much substance of a fleshy kind to penetrate with the trochar on the inner surface of the ribs, which induced Dr. Colhoun to conclude that I penetrated " far into the lungs." I have repeatedly performed the same operation since and evacuated pleuritic effusions after cutting through a very thick false membrane behind the intercostal space, which gave the same sensa- tion as my cutting into the substance of the lungs. The operation of paracentesis after pleurisy has now become very common, and if performed before the lung PNEUMONIA BILIOSA. 313 the reader is referred to the works of Werlhoff,* Donald Monroe, Stoll,t Richter,! Hoffman,§ B. Bell, and Aug. Gott. Richter.|| m! Jowett has reported a very interesting case of empyema successfully treated by this operation ;1T and we might go on to cite many more instances of this kind. I have been thus particular in referring to authorities in favour of this operation in cases of empyema or tho- racic effusion, from the equivocal manner with which it is spoken of by Dr. Gregory in his practice. "Paracentesis thoracis," he says," is probably advisable in certain cases both of vomica and empyema; but the observations of authors on this piece of practice are very scanty."** When there is reason to believe that hepatization of a portion of the lungs has taken place, benefit may still be obtained, in some in- stances, from external irritating applications. Frictions with tartar emetic ointment, or with an ointment made by mixin? two drachms of the white precipitate with an ounce and a half of lard, will answer well for this purpose. Setons, and caustic issues, also, are useful in cases of this kind; or continued blistering with emplast. lyttse. In- ternally, advantage may probably be derived from small doses of has become greatly shrunken, is generally successful. At all events, it enables the subsequent applications of blisters and mercurials to excite the reabsorption of false membranes on the pleura, and thus prevent a return of the effusion.—Mc] * Opera. Hanov., 1775, p. 775. t Ratio Medendi, vol. iii. p. 155. X Chirurgische Bibliotheck, band. 3, s. 464. Band. 4, s. 476. Band. 6, s. 590. Band. 7, s. 311. Band. 8, s. 728. $ Unterricht von dem Collegium der Aertze in Munster. II Medico-Chirurg. Observations. H Med. Chir. Rev., July, 1826. M. Jowett observes, "I have twice very re- cently had occasion to resort to paracentesis of the thorax, in hopeless cases of effusion arising from pleurisy. In both instances, the operation was the means of prolonging, although it did not eventually save, the lives of the individuals." To prevent the admission of air into the cavity, M. Jowett recommends the operation to be performed in the following manner: "Having made a small in- cision through the integuments only, in the place selected for the operation— which will, most commonly, be in the back, in the sixth or seventh intercostal space—thrust a small trocar carefully through the muscles and costal pleura- having withdrawn the trocar and left the canula in the wound, join a tube, con- nected with a Reid or Weiss' syringe to the canula, and slowly abstract the fluid by the syringe, continuing to work it as long as the piston moves freely, or until symptoms come on which render it necessary to desist. Then remove the ca- nula from the wound without previously separating it from the syringe; approxi- mate the edges of the integuments by plasters, and apply a compress to make it more secure." ** "The history of the operation of paracentesis thoracis for empyema or hy- drothorax, would well deserve an article in a periodical journal. Kurt Spren°-el has given a most erudite history of this operation, from the days of Hippocrates to the close of the last century, occupying eighty-seven pages of letterpress."__ Dr. Johnson, Med. Chir. Rev., vol. v. p. 273. 314 CYNANCHE LARTNGEA. muriate of mercury in union with conium or belladonna. One-tenth of a grain of this mercurial, with from two to three grains of the extract of conium, may be given three times daily. Diuretics, also, have been recommended both in hepatization and in suppuration of the pulmonary tissue—more especially in thoracic effusion. When suppuration has occurred, the strength of the system should be sup- ported by digestible and nutritious diet, opium, or extract of conium —but the more diffusible stimulants must be avoided. Sect. II.— Cynanche Laryngea.—Laryngitis. Until within a comparatively recent period, laryngitis was gene- rally confounded with croup, to which, indeed, it bears a considerable resemblance. Boerhaave refers to this disease in section 802 of his aphorisms, and Van Swieten quotes a strongly-marked case from Tulpius.* More recently, Drs. Farr, E. Percival and Home,t have published interesting papers on the pathology and treatment of this severe and dangerous variety of cynanche ; and the chapter on this subject in Dr. Armstrong's work on typhus, may be advantageously consulted. The disease usually commences with the ordinary initial symptoms of inflammatory fever; the patient experiencing at first slight, sensa- tions of chilliness alternating with flushes of heat. A feeling of sore- ness in the fauces, attended with more or less tenderness to pressure in the larynx, and uneasiness in swallowing, are among the first symptoms. The voice soon becomes changed into a thick, slightly hoarse whisper, and on strong inspiration, the air seems to enter im- pededly, as if it were forced through a very narrow aperture, and is attended with a hoarse, dull, hollow sound. On examining the fauces, they exhibit a pale red, tumefied, and ODdematous appearance. The expectoration is not abundant, and consists almost wholly of saliva of a ropy character. The pulse is generally frequent, contracted, and tense ; but in some cases it is but very little disturbed. The face is for the most part pale, and the tongue white, punctuated with red points, and covered with a layer of transparent mucus. When the disease is fully developed, deglutition is very difficult and painful, and apt to excite alarming and distressing paroxysms of suffocative breathing. The temperature of the surface is unequal, being higher than natural in some parts, and lower in others. One of the most peculiar and characteristic symptoms of this affection, says Dr. Arm- strong, is the inability of patients to cough out, as is done in pulmo- nic or catarrhal affections ; the attempt to do so resulting in a kind of suffocating effort, terminating " in a low, grumbling, and almost grunt- ing sort of noise in the throat." Respiration somewhat impeded from the onset of the disease, becomes more and more oppressed and labo- rious as the disease advances, with occasional violent and distressing * Observ. Medicar., lib. i, cap. 57, p. 96, t Medico-Chirurg. Transact^ vol. iii, p. 268, CYNANCHE LARYNGEA. 315 paroxysms of dyspnoea, until at last, in unsubdued cases, death occurs by actual suffocation.* In some instances, laryngitis is as insidious in its approach as it is rapid and fatal in its progress. Mr. Porter knew two instances of young men who went to bed at night, without complaining of any illness, "and were found dead from this affection the next morning." M. Leveille has reported a case of laryngo-bronchitis, which was so masked by erysipelas of the face, as to escape observa- tion until within a few hours of its fatal termination.! "The seat of this affection," says Mr. Porter, "is more in the cellular tissue, connecting the mucous membrane with the adjacent parts, than in the membrane itself, although this latter structure is very frequently found to have been inflamed." The epiglottis, rima- glottis, soft palate and larynx, are always tumefied and osdematous by inflammation and serous effusion into the submucous cellular tissue, so as to approximate the sides of the glottis and prevent the passage of air into the lungs. In some instances the inflammation is confined to the larynx, but it occasionally is found to have extended down the trachea and even into the bronchia. (Armstrong.) Porter, however, observes, "I can find no satisfactory examples of the in- flammation having extended beyond the larynx and into the trachea; on the contrary, the chief intensity of the disease has been in the epi- glottis, which is found red, erect, thickened and swollen, and during life resembles a piece of raw meat."J In the case reported by Le- veille, the inflammation was manifest from the larynx down along the trachea and in the bronchia. The inflammation has heen known to terminate in the formation of one or more abscesses in the parts surrounding the larynx. Arm- strong mentions a fatal case in an old woman, in which "a con- siderable abscess was found bet ween the muscles of the pharynx and the bodies of the cervical vertebrae." In some instances false membrane is found on the epiglottis, tonsils and trachea. Treatment—Laryngitis is to be regarded as one of the most rapid and dangerous affections. It often terminates fatally in less than twenty hours, under the most prompt, energetic and judicious modes of treatment. Blood-letting is unequivocally indicated, and yet its effects in arresting the progress of the inflammation in this affection, do not appear to equal those it manifests in other varieties of tracheal inflammation. Dr. Armstrong asserts, that in one in- stance, "one hundred and sixty ounces of blood were drawn within * [■' This formidable malady has always existed, for you may trace examples of it, under various names, even in the writings of the ancients. But it is only in recent times that it has been singled out from the rest of the anginae, and made a separate object of study. It has numbered some distinguished medical men among its victims : Dr. David Pitcairn, Sir John McNamara Hayes, Sir George Tat- hill. The celebrated General Washington died ofit."—Watson's Lectures, p, 443.] t Gazette de Sante, 1827. X Observations on the Surgical Padiology of the Larynx and Trachea, &c, By VVm. Henry Porter, p. 98. 316 CYNANCHE LARYNGEA. the space of six hours," by venesection and leeches, yet " so far from arresting the inflammation, the patient died within twenty-four hours." In only one case out of six, he says, did blood-letting ap- pear to afford unequivocal advantage. It must be admitted, indeed, that bleeding does not often procure any prominent benefit in this affection; and yet who would undertake to treat the disease without resorting to prompt and efficient depletion ? Dr. Beck, of New York, attributes the" want of success of this measure in laryngitis to the inefficient manner in which it is usually employed. When carried to the extent of producing syncope, it is, he thinks, as likely to do good in this as in other inflammatory affections of the respiratory passages. My own experience does not, however, entirely confirm this observation. Nevertheless, blood-letting to the extent of pro- ducing fainting must be regarded as an indispensable auxiliary in the treatment of this affection.* Leeches should be largely applied to the throat. Martinet has reported a case which terminated suc- cessfully under the employment of general and local bleeding and blistering. In the course of three days upwards of 40 ounces of blood were drawn with the lancet, and 110 leeches applied to the throat and back of the neck. Blistering the throat or the back of the neck, while leeches and emollient poultices are applied to the throat, will in general assist materially in the reduction of the dis- ease. Armstrong places more reliance on the repeated employment of antimonial emetics in this disease, than on any other remedial measure. After having found blood-letting and local applications ineffectual in the majority of cases that had come under his care, he was induced to try the effects of emetics, "given in repeated doses, till free and frequent vomiting was produced." He accordingly gave antimonial emetics in five cases, for which he was subsequently called to prescribe. " No circumstance in my professional life," he says, " ever gratified me more than the great and sudden relief which vomiting afforded ; in reality it removed all the urgent symptoms at the time, and being re-excited as soon as ever the slightest signs of * ["How and when are we to employ the great remedy for acute inflammation-- blood-letting? or are we to employ it at all? These are points concerning which it is quite necessary that our minds should be prepared and prompt to decide. If you look merely at the results of the recorded cases of this fearful complaint, you will scarcely find an answer to the question. In some of them, copious bleeding appeared to save the patients; in others, it was of no service, but rather seemed to accelerate their death. Sir John McNamara Hayes suffered two attacks of cy- nanche laryngea. In the first he was bled freely. Dr. Roberts, of Startford, in- forms us that the first bleeding was attended with considerable relief, the second also with manifest advantage, and by the third, his safety appeared to be ensured. Fif- teen years after, he died of the same disorder, for which he was again bled and leeched under the care of the late Dr. Baillie. Washington was largely bled and died. Again, Dr. Francis, of New York, recovered from acute laryngitis after copious venesection. It is evidently needful to consider and determine the circum- stances under which we are to use or to withhold the lancet."—Watson''s Lectures p. 444.] CYNANCHE LARYNGEA. 317 stricture in the larynx returned, at last completed the recovery." In a well-marked case which I recently attended, in a child about four years old, blood-letting to the extent of about ten ounces, with a blister to the throat, and three active emetics, effected a cure. Pur- gatives must not be neglected in the management of this affection. Calomel either by itself in large doses, or in union with rhubarb or jalap, should be given so as to keep up a free action of the bowels. Some advantage may, perhaps, be derived from warm and stimu- lating applications to the feet, such as warm pediluvia or sinapisms. Dr. Good recommends the use " of gargles of ice water acidulated, and epithems of pounded ice applied externally," in preference to blisters to the throat. I have seen an instance of this disease in which the application of a solution of lunar caustic, by means of a soft pencil to the inflamed fauces, (as is recommended by Mackenzie in the somewhat similar affection, recently described by Bretonneau, under the name of diphtherite,) was evidently beneficial. It is probable that the insufflation of very finely powdered alum into the fauces, (a practice successfully adopted by Laennec in cynan- che trachealis,) would prove beneficial in this affection. The pow- dered alum may be blown into the fauces through a small tube or quill The operation of bronchotomy is recommended by some writers, where the remedies already mentioned do not make any effectual impression on the disease. « Besides the uncertainty that must pre- vail as to the precise nature of the morbid action that is going on in acute laryngitis, and the consequent hazard a practitioner will run of losing his patient, whilst he is attempting a treatment that may be unsuccessful, there are many reasons why he should in the present instance decide at once on the performance of bronchotomy. Thus it allows the organ in which the diseased action is situated to remain in a perfect state of repose. Considered as a wound, it adds nothing to the patient's danger; and as the relief it affords is, at least, for a time, complete, it imparts confidence to the surgeon, and allows him more leisure to examine the symptoms and adopt the remedies ac- cordingly. If, however, the operation be not early performed, it had much better be let alone altogether."* A highly interesting instance is related of the successful perform- ance of tracheotomy, in a case of laryngitis, by Dr. Crampton, in the fourth volume of the Dublin Transactions. Professor Regnoli, also, has reported two successful instances of this operation in chronic laryngitis. The acute form of the disease, he observes, sometimes terminates in chronic cedematous tumefaction of the epiglottis, and the mucous membrane of the larynx, with or without thickening of the submucous cellular tissue, which will ultimately render respira- tion extremely difficult, and even cause death by suffocation. Here bronchotomy is the only means of relief in our power.t * W. H. Porter. Loc. citat, p. 100. t Nuovo Mercurio delle Scienze Mediche. Mazo, 1829.—See Rev. Medicale, Juin, 1829. 318 CYNANCHE TRACHEALIS. Sect. III.—Cynanche Trachealis.—Croup, Hives. Symptoms.—This disease sometimes comes on suddenly, and ac- quires the utmost degree of violence in the course of a few hours. More commonly, however, its approach is gradual, the first symp- toms being those of ordinary pulmonary catarrh. A dry and hoarse cough, with slight difficulty of breathing, and a change of the voice, are generally the first intimations of its invasion. This very peculiar hoarse and rough cough, with its accompanying slightly oppressed breathing, continues sometimes, with occasional remissions, for seve- ral days, before the disease assumes its characteristic form and vio- lence. More or less febrile excitement is generally present, from the very commencement of the disease. Sooner or later the respiration becomes more difficult and distressing; the febrile reaction rises higher; the voice becomes more indistinct, whispering, or annulled; slight pain and uneasiness are felt in0 the larynx; and the cough be- comes more sonorous. The disease now advances rapidly to its state of full development, and all the symptoms acquire a most alarming and distressing degree of violence. The countenance is flushed; the eyes prominent, injected and heavy; the pulse frequent, tense, and quick; the skin dry and hot; and the respiration extremely difficult and anxious. Inspiration is especially difficult, and accompanied with a very peculiar ringing or stridulous sound. The cough at this time is often quite dry ; but in some instances, there is a copious and very tenacious albuminoid fluid secreted in the larynx and trachea, from the very onset of the disease, and in all cases, this viscid secre- tion occurs in the advanced stage of the malady. If the disease be not checked in its violence and progress, the breathing acquires, at last, a degree of oppression inexpressibly distressing; the little patient manifests, in the expression of its countenance and actions, the utmost degree of anguish and suffering ; the head is thrown back- wards, and the mouth kept open: the eyes are half closed or cast about with an imploring expression for relief; the voice is extinct; the lips livid; the face pale and covered with large drops of sweat; sensibility rapidly diminishes; slight coma ensues; the extremities become cold and clammy ; and finally breathing stops and closes the agonizing scene. Such are the ordinary course and symptoms of this frightful ma- lady. Much diversity, however, occurs in relation to the degree of violence and rapidity of these phenomena. In some instances, not more than a few hours elapse between the commencement and fatal termination of the disease. In other cases, the symptoms proceed slowly to their acme, and the disease is protracted for many days, and occasionally even for several weeks, assuming a chronic character, without, perhaps, having at any time manifested a very alarming degree of violence. The ordinary period occupied by this disease, is from two to five days. Causes.—Cynanche trachealis is one of those inflammatory affec- tions for which a predisposition appears not unfrequently to be con- CYNANCHE TRACHEALIS. 319 genital. It is certain, at least, that the children of some families are particularly predisposed to the disease, whilst, in others, it never makes its appearance. In what this predisposition consists, we can- not tell. To say that it depends on a peculiar organization of the mucous membrane of the larynx and trachea, may be correct-; but what these organic peculiarities are, it would be in vain to inquire. Besides this original or natural predisposition, there is another one much more universal and influential in its agency, namely, age. Cy- nanche trachealis is, indeed, almost peculiar to the age of childhood, being vastly more common in children between the first and fifth year of age than in the whole subsequent and anterior periods of life. It is, nevertheless, not wholly confined to the years of infancy and childhood ; for occasionally, though rarely, it occurs in adults, and sometimes even in very advanced age. This aptitude to the dis- ease in early childhood may depend, in part, on the peculiar condi- tion of the glottis or larynx at this age; for, that there exists some peculiarity in this portion of the respiratory passage, during infancy and childhood, unconnected, probably, with mere size of aperture, is manifest from the characteristic voice, at this early period, and its remarkable change during the period of pubescence. But there is another circumstance which may have a large share in the so com- mon occurrence of this malady during infancy, namely, the almost universal custom of dressing children so as to keep the neck and upper part of the thorax perfectly bare, and thus rendering them more liable to the injurious influence of cold in these parts. Certain exanthema- tous affections, also, often give rise to an increased aptitude for this disease. This is especially the case with scarlatina, measles and miliary fever. Observation would seem to show that florid, robust and fat children are much more liable to the disease than those who are of an opposite habit. The principal exciting cause of this disease, is cold or sudden vicissitudes of atmospheric temperature; and hence its greater pre- valence during the variable, damp, and cold months of autumn and spring, than in the more temperate and uniform season of summer. Cynanche trachealis is said to have prevailed epidemically; but con- trary to what obtains, in this respect, with epidemic catarrh, these epidemic cynanche are, always, of a very limited sphere, with regard to the extent of country which they embrace. In general, this dis- ease is most apt to prevail after, or during the prevalence of measles or scarlatina. During convalescence from these affections, there exists an especial aptitude to cynanche from the influence of cold. It would seem, too, that the liability to this disease is often considerably in- creased, by having suffered an attack of it. I have known the same individual suffer five or six attacks of the disease, during the period of childhood. Cynanche trachealis is a phlegmasial disease, consisting essentially of inflammation of the mucous membrane of the superior portion of the respiratory tube. The correctness of this pathology is confirmed not only by the known character of its most common exciting cause, but especially, also, by the more direct evidence of the symptoms of 320 CYNANCHE TRACHEALIS. the disease, and the appearances discovered on post-mortem exa- mination.* The observations of Bretonneau in France, and of Mackenzie in England, published within a few years past, go directly to the esta- blishment of this view of the nature of the disease. Both these observers assert that the inflammation often commences in the fauces and on the tonsils, and descends thence into the trachea; a progress of the disease, which may be verified by ocular inspection. I have myself seen several cases of croup, which commenced by a kind of erysipelatous or superficial inflammation, about the tonsils and soft palate; and in one instance, this inflammation continued for four days, and was the object of medical attention before it extended into the trachea and gave rise to the symptoms of croup.t The inflam- mation which occasions the characteristic phenomena of this disease, * [Although croup consists essentially in an inflammation of the lining mem- brane of the trachea, (i. e., in the part below the larynx and above the bifurca- tion into the bronchi,) the disease sometimes extends higher up so as to affect directly the larynx, and still more frequently lower down so as to occupy the extreme ramifications of the bronchi. When the inflammation does not extend upwards into the larynx, the muscles of the glottis may nevertheless be thrown into spasmodic contraction by reflex sympathy. Dr. Watson, in his lately published lectures, makes the following excellent observations. " Cullen makes no dis- tinction between cynanche trachealis and cynanche laryngea. Yet they are separated from each other by very definite boundaries. They differ in anatomi- cal position; they differ in gravity. Both, indeed, are serious diseases, but croup is the more serious, because it seldom admits that mechanical relief (tracheotomy), which, when rendered in time, deprives cynanche laryngea of its dangerous cha- racter. The two disorders differ also in respect to the period of life at which they occur. Idiopathic laryngitis is seldom met with except in adults, croup seldom after the age of puberty. Cynanche trachealis is, indeed, a very remarkable dis- ease,—for it exhibits an event of inflammation which does not usually belong to that process when it affects the mucous tissues. In this, too, it differs from laryn- gitis. I say that croup is peculiarly a disease of early life. The interval that lies between the two periods of weaning and puberty is the time during which its visitation is chiefly to be apprehended. Comparatively few cases of it occur during the first year of infantile life. There are more in the second year than in any other."—" Some of the cases recorded of croup in the adult, were probably in reality cases of laryngitis. It is curious that inflammation should thus at different epochs of life fix itself upon limited portions of the same continuous surface, and give rise to consequences so diverse. We are unable to give any account of this." —Mc] f It is surprising that a disease so manifestly phlogistic in its character, should still be viewed by some of the German and French writers as essentially spas- modic in its nature, or at least, as wholly independent either of a local or gene- ral inflammatory condition. Several of the late continental writers on this dis- ease regard the fever and inflammation, which they acknowledge sometimes to exist, as wholly accidental, and as in no manner essential to the perfect constitu- tion of the malady. Among the principal antiphlogistic pathologists, in relation CYNANCHE TRACHEALIS. 321 rarely remains confined to the larynx and trachea. In many instances, it extends downwards into the bronchia, and sometimes even into the small ramifications, giving rise to the simultaneous existence of acute bronchitis and laryngeal inflammation. The danger from this disease is always greater, cseteris paribus, in proportion as the in- flammation passes down into the bronchial ramifications. Indeed, when bronchitis coexists extensively, the result must almost inevita- bly prove unfortunate. In some instances, the laryngotracheal inflammation terminates, after a shorter or longer period from its commencement, in tne for- mation of a false membrane; which, according to the latest and most accurate observations, appears to consist of a concrete albuminoid secretion.* In other instances, the inflammation terminates in the secretion of a muco-purulent matter of an opaque and yellowish ap- pearance, without the formation of a pseudo-membranous substance. There are other cases, again, and these are perhaps much the most common, in which the inflammation produces neither false membrane, nor a puruloid matter, but an extremely copious secretion of a very viscid, limpid, and frothy mucus.t M. Bland, in his excellent work on this disease, maintains that these different modes of termination constitute good grounds for dividing the disease into three principal varieties, indicating three different grades of inflammation. The in- flammation, he says, is at the highest grade of violence, in those cases which are attended with the formation of false membrane. It is less violent in the instances where there is only a muco-purulent fluid formed; and in those cases in which a copious secretion of a tenacious, limpid, and frothy mucus occurs, the inflammation is at its lowest grade. In the first and most aggravated variety of the disease, the cough and respiration are always dry, or free from that peculiar rat- to this affection, may be mentioned Des-Essartz, Banafox, (a) Ruette, (b) Schneck,(c) Lobstein, (rf). Professor Nasse regards impaired or disturbed func- tion of the pneumogastric nerves, as the proximate cause of the disease. The symptoms which characterize this disease, he asserts, bear a very strong resem- blance to those which result from the division of the eighth pair of nerves. The inflammation which occurs in the mucous membrane of the respiratory passages, is, according to his views, secondary, and the consequence of the disordered function of the pneumogastric nerves. * According to the experiments of Schwilgue, this membranous substance is insoluble both in cold and in boiling water, but perfectly soluble in a solution of the alkalies. By incineration, it yields deuto-carbonate of sodium, proto-phos- phate of lime, &c; corresponding, thus, entirely with the properties of coagulated albumen. t Nouvelles Recherches sur la Laryngo-Tracheite. Par P. Blaud. A Paris, 1824. (a) Journ. de Med. Chir. Pharm., &c, torn, xxxvii. November, 1816. . (6) Traite de 1 Asphyxia connue sous le nom de Croup. (c) Bib. Med., torn, xii, p. 256. (d) Mem. de la Societe Med. d'Emulation, 8° annee, 2e part, p. 538. VOL. I.—21 322 CYNANCHE TRACHEALIS. tling sound in the respiratory passages, which occurs, when these contain viscid secretions. This dryness of the cough usually continues for many hours after the disease is fully developed. The pain in the larynx is often very considerable, and the febrile reaction is generally violent. The period at which the false membrane is formed, after the commencement of the inflammation, appears to vary considerably. In some cases M. Blaud found the larynx and trachea lined with such a membranous substance, although the whole course of the disease did not occupy more than twenty hours ; in other instances, several days appeared to elapse before it was formed. Occasionally, only a part of the internal surface of the larynx is found coated with this concretion ; but in some instances, it has been found to extend into the bronchia, and even into the smaller divisions. Sometimes, instead of a membranous expansion, we find, on dissection, the upper part of the trachea almost entirely blocked up by a thick mass of the concreted albuminoid secretion, lodged just within the glottis. In cases in which this membranous substance is not formed, the cough early becomes somewhat humid, and the respiration rattling; and before the disease has continued many hours, the mucus in the larynx and trachea is so copious as to threaten suffocation by obstruct- ing the glottis. M. Blaud thinks that the extremely viscid mucus which is formed in these milder cases, is entirely different in its pro- perties from the secretion which occurs in the former variety—and that it is incapable of being so inspissated as to give rise to a pseudo- membranous substance. Whatever may be thought of M. Blaud's division of this disease, or of his sentiments in relation to the radical distinction between the inflammation and secretion which give rise to membranous structures, and that inflammation and its consequent mucous secretion which occur in cases unattended with the formation of false membrane, it must be admitted, that there exists at least a twofold diversity in re- lation to the immediate local consequences of the laryngotracheal inflammation—namely,one variety in which false membrane is formed, and in which the cough and respiration are at first dry, or do not in- dicate the existence of much mucus in the respiratory passages; and another variety in which the cough and respiration are humid, in the early period as well as throughout the disease, and in which a very copious secretion of transparent and extremely viscid mucus occurs. The former are exceedingly dangerous, nay, almost hopeless, unless subdued by the most prompt and powerful antiphlogistic measures, in their very onset. The latter are much less dangerous, and may gene- rally be cured by more moderate antiphlogistic measures, and the expulsion, from time to time, of the tenacious mucus from the larynx and trachea. In nearly all cases, the mucous membrane of the larynx and tra- chea is found very manifestly congested on dissection ; and the glottis is frequently considerably narrowed by a kind of thickening or tume- faction of its lips. With regard to the ratio symptomatum, it may be observed, that the immediate cause of the distressing difficulty of respiration, and CYNANCHE TRACHEALIS. 323 finally of death, consists in an obstruction to the passage of the air into the lungs. The circumstance which causes the exclusion of the air from the lungs consists either in a spasmodic closure of the glottis, or, in an occlusion of this aperture by tumefaction of its sides, or, by the formation of false membrane or a mass of concrete lymph, or, finally, by an excessive quantity of a very ropy and viscid mucus closing up the passage. Death is also sometimes the immediate con- sequence of a copious serous effusion into, and consequent choking up of, the bronchial cells, a mode of termination which almost al- ways occurs when the inflammation descends into the bronchial rami- fications. Spasmodic contraction and closure of the glottis may be caused by irritation excited by the upper portion of the false mem- brane. Prognosis.—Laryngo-tracheitis is always to be regarded as a very dangerous affection. Formerly the majority of cases terminated fa- tally ; but under the present improved pathology and mode of manage- ment, the proportion of fatal cases is greatly diminished. Frightful and unmanageable as this disease is, when suffered to pursue its course uncontrolled, or when opposed by inadequate means, it is, ne- vertheless, almost as much under the dominion of a prompt and vigo- rous antiphlogistic treatment, as any of the more serious phlegmasial affections. The degree of danger appears to be proportionate to the violence of the inflammation, and the extent to which it may have passed downwards into the pulmonary passages. It would seem, also, that the more, sudden the attack, when attended with strong febrile excitement, the greater, in general, is the danger. When, how- ever, the disease supervenes suddenly without fever, the attack may be presumed to be purely spasmodic* and may readily yield. The shriller and more sonorous the cough, the more reason is there to ap- prehend danger. It must be observed, however, that the prognosis in this disease is often exceedingly fallacious. Sometimes the symp- toms yield, and promise a speedy convalescence, when a violent ex- acerbation will suddenly supervene and destroy the patient; and on the other hand, death may appear to be impending, when on the sudden expulsion of a membrane, or even without such an occurrence, a rapid change for the better will ensue, and lead on to full conva- lescence. Diagnosis.—There is but one disease which may be mistaken for laryngo-tracheitis, namely, spasmodic or cerebral croup. From this latter form of disease it may be distinguished: by/ 1. The attack of cynanche laryngo-trachealis generally coming on gradually, with the ordinary initial symptoms of catarrhal affec- tions; spasmodic croup always supervenes suddenly, and is rarely preceded by catarrhal symptoms. When the former does come on suddenly, which is sometimes the case, it is so manifestly a febrile affection, that, by this circumstance alone, it may be readily distin- guished from the spasmodic disease. * fJnder the head of Asthma, in the second volume, some observations are made on Spasmodic Croup. 324 CYNANCHE TRACHEALIS. 2. Cynanche is essentially a febrile affection; spasmodic croup is free from fever, except it be accidentally present. 3. Cynanche is often attended with considerable remissions, but not with complete intermissions, except perhaps immediately after vomiting. Spasmodic croup is, often, marked by complete intermis- sions, of considerable duration. 4. Cynanche is always attended with a hoarse and sonorous cough, and frequently with a copious secretion of viscid mucus in the tra- chea. Spasmodic croup is rarely accompanied with much cough, fre- quently none at all, and it is always dry.* 5. The peculiar stridulous sound of the cough and inspiration, so characteristic of cynanche laryngo-trachealis, does not occur in spas- modic croup. 6. In spasmodic croup the pulse is small and contracted, and the skin not above the natural temperature. In cynanche, the pulse is excited and irritated, being generally full, frequeut, quick, and tense ; and the temperature of the surface is febrile, except towards the fatal conclusion of the disease, when, from the imperfect func- tion of respiration, animal heat ceases to be generated in its normal proportion. Treatment.—From what has been said above of the nature and character of this disease, it is obvious that the general indications to be kept in view in its treatment are: 1, To subdue the local and general inflammatory action as speedily as possible ; and, 2, to pro- mote the discharge of the viscid and coagulable secretions which are lodged within the superior portions of the respiratory tube. For the fulfilment of the former of these indications, the most prompt and energetic antiphlogistic measures must be adopted. He who loses sight of, or neglects this all-important indication, and places his hopes in one or more of the empirical remedies that have, by different prac- titioners, been extolled for their supposed specific tendency to coun- teract the tracheal affection, will, we maybe confident, have but little reason to flatter himself for his success in the management of this malady.t The remedy upon which we must place our principal reliance for * Dr. Rush has published an account of a dissection of a child that had died of spasmodic croup. In this subject, no membrane, nor even mucus was found in the respiratory passages, nor did the lungs exhibit the slightest traces of previous disease. t It was owing to physicians not attending to the essentially inflammatory nature of this affection, and the consequent indispensableness of prompt and vigorous antiphlogistic measures, that this disease was formerly so much more frequently fatal than it appears now to be. It is also owing to this error, or rather to the erroneous views which have been so common concerning the pathology of this disease, that so many physicians have objected to the employment of blood- letting, and expressed their willingness to confide in mercury, poly gala senega, car- bonate of ammonia, and hepar sidphuris, to the exclusion of the direct and powerful antiphlogistic means, long since so universally arid so successfully practised by American physicians. CYNANCHE TRACHEALIS. 325 the reduction of the tracheal inflammation is blood-Jetting, in con- junction with external vesicating or irritating applications to the throat. Here, however, as in most of the other phlegmasial diseases, the good effects of the lancet are confined to the early period of the disease. If bleeding be neglected, or inefficiently employed, in the first stage of the malady, its progress will be extremely perilous, whatever other remedial measures may be adopted. When called to a patient labouring under this disease, in whom the manifestations of high febrile excitement and active tracheal inflammation are con- spicuous, a vein should be opened, and the blood suffered to flow until an approach to syncope is induced. As soon as this effect is produced, all the distressing symptoms usually subside. If in the course of an hour or two the difficulty of respiration reappears, and the pulse be not soft and feeble, more blood should be drawn, and again to the extent of inducing an approach of syncope. I have been obliged to open a vein three or four times in the course of twelve hours, before a permanent and decisive impression was pro- duced on the disease. Such copious depletion is, however, demanded only in cases where the local and general inflammatory action is strong—where the pulse is tense, hard, quick and vigorous, attended with a dry and sonorous cough and respiration. Such cases arc apt to terminate in the formation of a false membrane in the larynx; and our efforts ought to be prompt and vigorous to reduce the in- flammation below the grade necessary for the formation of pseudo- membranous matter. After the effusion which gives rise to the membrane has taken place, bleeding will afford but moderate and temporary advantage. It must also be observed, that where the disease is attended with but moderate symptoms of febrile excitement; where the pulse is not hard, or tense, though accelerated; and especially where, in ad- dition to these manifestations of a moderate febrile excitement, the cough and respiration are attended, early, with a copious, trans- parent and viscid mucus, blood-letting need very seldom be em- ployed to the extent just mentioned, and may even, in some instances, be wholly dispensed with.* Emetics are important remedies in this disease, and may, indeed, be regarded as indispensable in its remedial management. Assisted * In no country is blood-letting so actively employed in this, as indeed in all other inflammatory affections, as in America.. The value of this evacuation in the present disease has been long understood by American physicians, whilst in Europe it was, until lately, looked upon as an equivocal, if not an injurious mea- sure. Even those who admitted the inflammatory nature of the disease, bled but very sparingly. To this there are indeed some remarkable exceptions. Ferriar recommends bleeding, ad deliquium. (.Med. Histories.) "This," says he, •' is the essential point, without which no relief can be effected." The same practice is strongly inculcated by Drs. Bayley and Middleton. (Cases of Angina Trachealis, with the Cure, in Letters to William Hunter, M. D., 1781.) And in the late medical journals observations may be found equally favourable to decisive depletory mea- sures in this formidable malady. 326 CYNANCHE TRACHEALIS. ' by warm pediluvia, mercurial purgatives, and rubefacients to the throat, 1 have frequently subdued mild attacks of the disease without the aid of direct depletion. In those cases that are early attended with a copious secretion of viscid mucus in the larynx and trachea, emetics are especially useful. They tend not only to expel this tough mucus from the larynx, and thus to give a temporary freedom from the dyspnoea, but also to equalize the circulation and to pro- mote the cutaneous exhalation, as well as to diminish the general arterial excitement by the nausea which precedes and accompanies their operation. In infants affected with this disease, the occasional employment of an emetic is particularly important; for at this early age, no voluntary efforts are made to dislodge and expel the viscid secretion from the larynx, and which, if not removed, may by itself cause suffocation. In those violent cases, which manifest a highly inflammatory character, and in which the cough and respiration are dry during the first stage, there is commonly but little advantage gained from the operation of an emetic, so long as this dryness of the larynx and trachea continues. In such cases the proper period for the administration of emetics commences with the appearance of the viscid secretions, which always sooner or later occur in the respiratory passages, and from which the disease derives its most serious and dangerous character. Without doubt, from the general antiphlogistic tendency of nausea and emesis, some benefit may result from the exhibition of emetics before any morbid secretions occur in the larynx; but the peculiar advantages of this class of remedies are most assuredly more conspicuously displayed when the upper portions of the windpipe are clogged with a viscid fluid, which requires expulsion. In the advanced periods of the disease, there exists often so much torpor or insensibility of the system, in conse- quence of the imperfect decarbonization of the blood and vascular congestion in the brain, that great difficulty is experienced in pro- curing the operation of emetics. To obviate this gastric insensibility, and procure emesis, we must endeavour to diminish the sanguineous congestion in the head; and this may, in general, be readily accom- plished by putting the patient's feet in warm water, and applying a napkin wet with very cold water, to the head. The abstraction of blood, too, while the patient is supported in a sitting or erect posture, will rarely fail to ensure the operation of an emetic under the cir- cumstances in question. The articles I prefer as an emetic in this disease are calomel in combination with tart, antim. I commonly administer from five to six grains of the former article with one- fourth of a grain of tart, antim. to a child of from two to five years old. I have frequently given from eight to ten grains of calomel alone, and have very generally found it to excite active voming in a short time. The peculiar advantages which appear to me to belong to this practice, are the protracted and great degree of nausea which the calomel produces, an effect which has a powerful antiphlogistic tendency; and the alvine evacuations which almost always speedily ensue. Besides these effects, great benefit may be expected from the early constitutional influence of the calomel—an influence which in CYNANCHE TRACHEALIS. 327 the present disease, especially, is very generally acknowledged to be highly salutary. Be this as it may, universal experience decides in favour of the employment of emetics in this disease. Tart, antim., ipecacuanha, sulph. zinci, squills, sulph. cupri,have ail been used and recommended in this affection; and where the object is merely the expulsion of the tracheal mucus, or pseudo-membranous matter, any of these articles may answer our purpose.* In some instances, where the accumulation of the tenacious secretion is very rapid, it becomes necessary to repeat the emetic three, four, or five times in the course of twenty-four hours. M. Jadelot recommends the following mixture as en emetic in croup, after proper depletion has been practised : R.—Infus. polygalae giv. Syrup ipecac. 5L Oxymel scillae ^iij. Antimon. tart. gr. iss.—M. Take a spoonful every fifteen minutes, until vomiting is produced. Purgatives are useful auxiliary remedies in the treatment of this disease. In the onset of the complaint, the bowels should be briskly evacuated, and two or three evacuations should be subse- quently procured daily until the inflammation is subdued. After the first purge, which should be energetic, it is best to employ the gentler articles of this class of remedies; for very active catharsis tends to exhaust the resources of the system without procuring any peculiar advantages over milder aperients, and may even do harm. After the first cathartic, it will, in general, be sufficient to keep the bowels in a loose state by laxative enemata. Calomel, given with a view to its constitutional influence, is a re- medy which has been, and by many is still much extolled in the treat- ment of this disease. Many of the continental writers seem to look- upon it as decidedly the most valuable means we possess for removing the local tracheal affection. In our own country, too, this article has found some eminent advocates as a remedy in inflammatory croup. The late Dr. Rush placed great reliance on its powers in this disease ; for he asserts, that when given in large doses in the commencement of this disease, and continued afterwards in smaller doses," it is hardly less efficacious in this complaint than the Peruvian bark is in inter- mittents." Dr. Hosack also speaks very favourably of the employ- ment of calomel and James's powder in combination, given at short intervals in the second stage of the complaint; and the late Dr. Bard placed much reliance on its powers. That the constitutional influence of mercury is calculated to do good in croup, I am well persuaded from my own experience. It tends in no small degree to reduce the * I have, in a few instances, prescribed an infusion of the lobelia inflata, with the happiest effect. From its known very powerful influence upon the respira- tory function in asthma, independent of its emetic operation, there is some reason for presuming, that in relation to the present disease, it may possess peculiar virtues, and my limited experience with it inclines me to this opinion. 32S CYNANCHE TRACHEALIS. local laryngo-tracheal inflammation, and to counteract, as it would appear, the formation of the pseudo-membranous exudation. Its operation in this respect is, however, much too slow to afford particu- lar advantage in the more acute and rapid cases of the disease, many of which run to a fatal termination in less than twenty-four hours. Where the complaint assumes somewhat of a chronic character, we ought not to lose the advantages which may be derived from this remedy. My usual mode of giving this article after the first or second emetic is to exhibit one grain every hour or two, with about one- fourth of a grain of ipecacuanha. ' The warm bath, also, is a very useful auxiliary in the treatment of this disease. Employed along with the remedies already mentioned, its benefits are often very considerable, more especially where the skin is very dry and hot. Its usefulness is, however, confined to the early periods ; for, in the advanced stages, the skin is generally bathed with profuse perspiration, and the pulse weak and soft. Concomitantly with the preceding remedial measures, external rube- facient and vesicating applications to the throat ought in all instances, to be employed. One of the first measures after bleeding should be the application of a blister, or some irritating substance to the throat of the patient. I prefer the application of the spirits of turpentine to blisters or any other similar article. The action of the turpentine on the skin is prompt and powerful, and if the derivative powers of such applications be proportionate to the degree of irritation and pain they produce, few articles can equal the present one in this respect. A piece of flannel may be imbued with the turpentine and applied round the neck. Children seldom will bear this application for more than twenty or thirty minutes at a time. It must, therefore, be re- moved and reapplied from time to time, according to the violence and permanency of its effects on the skin. In general, it has appeared to me that active rubefacients are preferable to blisters in this complaint. They generally act with promptitude and force—a circumstance of no small consideration in a disease which often runs its course in a few hours. A blister requires frbm four to five hours before its effects on the skin can be of any particular avail. An efficient blood-letting ought always to precede such applications in cases attended with high febrile excitement. The oil of the monarda punctata, with an equal proportion of camphorated liniment, forms also an excellent rubefa- cient in this affection. Where the disease proceeds slowly, the use of a blister will be preferable to rubefacients. With regard to the local abstraction of blood by means of leeches, general experience does not enable us to ascribe any peculiar advan- tages to it. It has never yet appeared to me to afford any greater advantage than if the same quantity of blood had been drawn with the lancet. Besides the foregoing remedial measures, which may be justly re- garded as decidedly the most direct and powerful means for combat- ting this malady, a number of other remedies have been recommended — some of which have been distinguished by the title of specific. Among these pretended specifics, the poly gala senega and the hepar CYNANCHE TRACHEALIS. 329 sulphuris (deuto-sulphur of potassium) have attracted the most atten- tion. The former of these articles is without doubt, a useful medi- cine in certain states of this disease; but it is, most assuredly, far from possessing the powers which were formerly ascribed to it by Archer and others. In the commencement of the disease, especially in the more violent cases, it is objectionable on account of its stimu- lating properties; but after the complaint has been in some degree subdued, or lost its acute inflammatory character, its influence is often conspicuously beneficial. For the removal of the dry and hoarse cough and slight oppression of the respiration, which, in some in- stances, remain after the inflammation has been subdued, we possess no remedy equal in usefulness to the polygala. It is, moreover, a deci- dedly useful remedy in all instances of chronic croupy affections, and ■ in the catarrhal and pectoral affections which remain as the sequelae of this and other acute affections of the respiratory organs. It is best given in decoction. An ounce of the root to a pint of boiling water suffered to simmer for 15 or 20 minutes, and afterwards sweetened with honey. The dose "of thisjs about an ounce every hour or two, according to the urgency of the symptoms. With regard to the hepar sulphuris, a remedy introduced to the notice of the profession about sixteen years ago, in a prize essay on this disease presented to the French Ecole de Medecine* little can now be said in commendation of its powers. Its introduction was founded on the erroneous doctrine that croup consists essentially in a morbid coagulability of the tracheal mucus, and which, it was asserted, the sulphuret of potash had the power of preventing or altering. It need scarcely be observed, however, that a remedy which might possess such power, without, at the same, time, exerting any influence in subduing inflammation, could afford us but little advantage in this affection; and the result of later experience goes to show that this at first highly lauded remedy exerts no decided influence over the tracheal inflammation. It would be a waste of time, to pass in review the various other remedies of this kind, which have at times been praised, and again abandoned as curative means in this disease. As well might we look for specifics for the cure of pleurisy, phre- nitis, or gastritis, as to expect to find one for laryngo-tracheitis. It has'already been stated above, that the exudation of albuminoid fluid, which forms the false membrane, frequently commences on the surface of the tonsils, and thence spreads along the arches of the palate, and at last descending over the internal surface of the pha- rynx and oesophagus, as well as the larynx and trachea. According to the experience of Dr. Mackenzie, the application of a solution of the nitrate of silver to the tonsils, velum palati, and uvula, will, in such case, frequently remove the membranous crust completely, and produce speedy and great relief, and ultimately entirely remove all the symptoms. The solution employed by him is of the strength of a scruple of the nitrate of silver to an ounce of distilled water. I * Rapport sur les ouvrages envoyees au concours sur le croup, par la commis- sion chargee de l'examen et du jugement de ces ouvrages. Paris, 1812. 330 ACUTE BRONCHITIS. have seen one instance in which this application was made, and the result gave me a very favourable impression of this practice. It must of course be confined to those cases in which the fauces are found, on inspection, to present an irritated and inflamed condition.* Dr. Laennec has lately published a statement, from which it appears that insufflation of very finely powdered alum generally affords * great and speedy relief, not only in this variety of the disease, but also in cynanche laryngea and tonsillaris. As cases of this kind are not uncommon, the practitioner ought in all instances to examine the fauces; and where the soft palate and tonsils are found to be inflamed and oedematous, a local application of the kind just men- tioned ought at once to be made. The success of the treatment must depend materially on the prompt reduction of this primary extra-laryngeal inflammation. With a view of expelling the false membrane, emetics have been , recommended in the advanced period of the disease, and the records of medicine are not wanting in instances in which this object was effected by such a measure. It offers, however, but an exceedingly slender foundation to build any hopes upon. The same object has in one or two instances been obtained by exciting violent sneezing by blowing snuff into the nostrils through a small tube. As to the proposed operation of tracheotomy in order to detach and remove the membrane, all experience has so far decided against it.t Sect. IV.—Acute Bronchitis. Peripneumonia Notha. The pathological character of acute bronchitis is very closely allied to common catarrh ; and, in truth, the latter affection may be regarded as the lowest grade of mucous inflammation of the bronchia. (Hast- ings.) This form of pneumonic inflammation is most apt to attack * [I have applied the solution Of nitrate of silver, 30 grs. to the ounce, with decided effect; and I often use the solid caustic with great advantage. But the best results are obtained from the application on the outer integument covering the whole of the larynx and trachea so as to blacken, and in some cases, to vesicate the parts. This deadens the irritation of all the parts below and relieves the inflammation and hoarseness very speedily. I have twice known it to detach the included false membrane and cause the little sufferers to expectorate large masses of it in a tubular shape, in a very few minutes after the application.—Mc] t [I have repeatedly yielded to the urgent solicitations of my friends in con- sultation and performed the operation of tracheotomy under the most desperate circumstances of croup, but never with more than temporary relief. The diameter of the trachea is too small in young children, especially when diminished by inflammatory thickening and deposition, to admit of the successful introduction of any instrument to maintain the respiration. The subsequent profuse secretions always produce suffocation. Moreover, the effects of the original inflammation extend below the reach of an operation in most cases.—Mc] ACUTE BRONCHITIS. 331 old people and infants, or persons of phlegmatic and debilitated habits. It generally commences like ordinary catarrh, with lassi- tude, chilliness, slight cough, and a sense of oppression and tightness about the prascordia. In many instances, the disease seems at first of no very serious character. The patient complains of little or no pain in the breast—a sense of weight and constriction in the thorax being the only uneasiness experienced in that part. In these cases, the febrile symptoms are but moderate. As the disease continues, the oppression at the praecordia increases; the countenance becomes expressive of anxiety ; respiration becomes more and more laborious ; and is attended with a wheezing rattling sound, as if the air were forced through a narrow aperture clogged with a viscid fluid. In most instances there is some degree of hoarseness. In the advanced period of the disease, respiration is much more difficult in the recum- bent than in the erect position ; and hence patients generally desire to have the head and shoulders propped up with pillows. At first the cough is dry; but a copious secretion of viscid transparent mucus, resembling the white of eggs", soon takes place, and with it considerable abatement of the violence of the cough occurs. So long as the sputa preserve this appearance, the disease may be regarded as unchecked in its violence; but when the inflammation is about to terminate in resolution, the matter expectorated loses its transparency, "and becomes mixed with yellowish-white or greenish masses, which are scanty at first, but continue to increase more and more, until at last they compose the whole of the expectoration."* In nearly every instance of the disease, severe pain is felt across the forehead, vvhich is always greatly aggravated by coughing. When the secretion of mucus into the bronchia is very copious, and respira- tion much obstructed, considerable drowsiness usually occurs. The tongue is white, and covered with transparent mucus; the skin is dry, and its temperature generally but very little above the natural standard. The blood is, commonly, buffy and sometimes cupped. Infants are especially liable to this affection. In them the disease manifests itself by a short, quick, oppressed and wheezing respira- tion ; uneasiness by being placed in the recumbent position; slight cough, somewhat hoarse at first, but humid and rattling as the dis- ease advances; a uniformly pale and anxious countenance; pulse frequent and tense; skin above the natural temperature on the trunk —but the hands and feet are commonly cool, or about the regular temperature. Respiration varies greatly: occasionally it is easy and free—and then suddenly becomes alarmingly oppressed, threat- ening instant suffocation. The progress of the disease is usually rapid. If it be not arrested, the breathing becomes more and more oppressed; "the child falls into a comatose state; a slightly livid tinge makes its appearance on the lips, from which the pallid cheeks are not entirely free. But even at this late period, gleams of hope sometimes burst upon us. For a short time the difficulty of respi- ration may seem to subside, and the child to be better. But these * Clinique Medicale, &c. Far G. Andral. Deuxieme partie, p. 53. 332 ACUTE BRONCHITIS. hopes are very seldom realized ; for even the next exacerbation may terminate in suffocation.''* The disease sometimes terminates fatally as early as the third day, though more commonly its course is pro- tracted to the fifth or sixth day. Acute bronchitis is always attended with great muscular debility. In robust plethoric subjects, the febrile reaction in the early period of its course is sometimes as vehement as in pleuritis. In cases of this kind, the inflammation generally passes to the substance of the lungs. Little or no pain, however, is felt in the breast; but the tight- ness and oppression are extremely distressing, and the breathing very laborious. Unless the inflammation be promptly subdued, effusion into the bronchial cells will take place; the lips become purple; the face and extremities cold; the pulse small, labouring and obstructed; the breathing short and incomplete; and at last drowsiness, partial coma, and suffocation close the scene.* In some instances, acute bronchitis is complicated with hepatic disease; a complication which occurs, not unfrequently, in persons addicted to the intemperate use of spirituous liquors. (Hastings.) Cases of this kind, besides the pneumonic symptoms already men- tioned, are attended with tenderness and fullness of the right hypo- chondrium, oppression in the praecordia, nausea, bitter taste, vertigo, headache, dark-coloured, and very fetid alvine discharges; and in some instances symptoms of acute hepatic inflammation attend, more especially when the .bronchitis occurs after measles. In children, cynanche trachealis often terminates fatally by the supervention of acute bronchitis. Diagnosis.—The characteristic symptoms of acute bronchitis are: great oppression and tightness in the breast, with little or no pain; severe pain in the forehead, greatly aggravated on coughing; a wheezing rattling respiration ; uneasiness in the recumbent position ; pallor of the countenance; a very copious secretion of viscid, frothy, and transparent mucus in the bronchia;! and generally a moderate grade of febrile excitement. Post-mortem appearances.—In very acute and rapid cases, the lungs do not collapse on opening the thorax, and its whole structure appears to be engorged with a frothy serous fluid. The mucous membrane is generally minutely injected—sometimes throughout its whole extent, and occasionally only in patches, the intermediate parts being nearly in a natural state. The smaller branches of the bron- chia are usually filled with a tenacious mucus, bloody serum, or purulent matter. In acute bronchitis succeeding pustular exanthe- matous affections, minute ulcerations, with uniform redness of the mucous membrane, frequently occur. In many instances, the sub- stance of the lungs exhibits a reddened, hepatized, suppurated, or * A Treatise on Inflammation of the Mucous Membrane of the Lungs. By B. C. Hastings. f M. Andral says this mucus resembles the white of eggs, and is extremely tenacious. Its tenacity and viscidity increase in proportion as the irritation of the mucous membrane is more considerable. ACUTE BRONCHITIS. 333 tuberculated structure; and occasionally even the pleura is found inflamed with incrustations of false membrane, or effusion into the cavity of the thorax.* • The wheezing respiration, and the great difficulty of breathing in this affection, are caused, no doubt, says Dr. Hastings, by the mecha- nical impediment to respiration from the redundant viscid mucus lodged in the smaller branches of the bronchial tubes; and the severe headache, arises probably from " the congestion of the pulmonary blood-vessels," interfering with the due return of blood from the head. Deficient decarbonization of the blood would seem to be the cause of the great muscular prostration which always attends severe cases of this disease. Although the phenomena just mentioned are very generally pre- sented on dissection, I do not doubt that death sometimes occurs in consequence of the inflamed mucous membrane preventing the at- mospheric air from producing the necessary change in the venous blood. M. Andral, jun., has related some cases of mortal dyspnoea from bronchial inflammation, where no effusion had taken place, nor any lesion of the parenchymatous structure of the lungs. When the pulmonary mucous membrane is intensely inflamed, the neces- sary influence of the atmospheric air upon the blood, it may reason- ably be presumed, will be more or less diminished ; for it can scarcely be doubted, that whether the oxygen enter .into the blood-vessels, or the carbon be thrown out through the delicate mucous membrane, much impediment will be produced to this process, when this mem- brane is deeply inflamed and thickened. The dyspnoea occurring in the early stage of bronchitis, is, perhaps, mainly attributable to this cause, and not to the clogging of the bronchial cells by viscid mucus, as is generally supposed. Patients often die in this disease, it would seem, from asphyxia—the inflamed mucous membrane opposing the transit of the carbon from the blood to the bronchial cells, or of the oxygen of the air into the circulation. The prognosis in this affection is generally attended with much uncertainty ; for in cases which appear to be going on without any particular "danger, a sudden exacerbation will sometimes occur, and speedily terminate the patient's life. Death, in this disease, is almost always preceded by more or less coma, and occurs, generally, from effusion taking place into the substance of the lungs and bronchial cells. A copious expectoration is always a favourable sign in this, as in the other varieties of pneumonic inflammation. The less tho- racic oppression and dyspnoea there is, the greater will be the chance of recovery from this disease. Treatment.—Much discrepancy of opinion has been expressed with regard to the value of blood-letting in this affection—some con- sidering this evacuation as attended with much risk, on account of the great tendency to prostration and effusion into the lungs connected with the disease, (Richter,) whilst others rely, with much confidence, on prompt and decisive blood-letting. With proper discrimination, * Hastings, loc. citat., p. 186. 334 ACUTE BRONCHITIS. the abstraction of blood may be as beneficially resorted to in this, as in any other form of pneumonic inflammation. In the acute bron- chitis of very old persons, or of worn out anfl debilitated habits, it is, indeed, necessary to proceed with much caution in the use of the lancet; but even in cases of this kind, moderate bleeding, soon after the com- mencement of the disease, will in most instances prove serviceable. In infants, when I have been called early, I have almost uniformly resorted to one very decisive bleeding; and generally, with unequivo- cal advantage. In the rapid and violent instances which occur in robust, vigorous and plethoric habits, prompt and very efficient bleed- ing is indispensable. In all cases, however, and particularly in the latter variety, the blood should be taken at an early period—as soon after the development of the inflammation as possible. If delayed until effusion or a copious secretion of bronchial mucus has taken place, the chance of benefit from it will be greatly diminished, and detriment probably be the consequence. So long as the cough is dry, we may draw blood, with a fair prospect of advantage ; and a suffi- cient quantity ought to be taken away, at the first bleeding, to make a manifest impression on the action of the heart and arteries; for a repetition of it will seldom be borne more than once or twice. Cathartics are recommended by some writers, but, except in the very commencement of the complaint, they are of doubtful propriety. The bowels should be kept in a loose state by laxative enemata, or the exhibition of the milder aperients, such as castor oil, or small portions of one of the laxative neutral salts. When, however, the disease is complicated with abdominal disease, cathartics may be freely employed with much advantage. Emetics are generally recommended as among the most useful re- medies in this affection. They usually prqcure immediate relief of the oppression in the chest and dyspnoea; and are apt to excite general diaphoresis, as well as more free expectoration. In the bronchitis of infants, they are especially serviceable, by expelling the viscid mucus which clogs the bronchial cells, and thus facilitating respiration, and, thereby sustaining the powers of the system. Hastings observes, that an aqueous solution of tartar emetic is the best medicine for this purpose in adults; and ipecacuanha in children. I have generally preferred using a mixture of vinum antimonii and syrup of squills, in children labouring under this complaint. From 15 to 20 drops of the former, with half a teaspoonful of the latter, may be given every twenty minutes to a child from one to three or four years of age, until vomiting is produced. Expectorants also are useful remedies in this affection. In the early period of the disease, mucilaginous mixtures, or antimonials, should be employed for this purpose. Thus : R.—Tart. Antimonii gr. ii. Sal. tartar, gvi. Aq. fontanse ^iiss. Mel. optim. Sjiiss.—M. ft. S. A tablespoonful eveiy hour for an adult. But after the general arterial excitement has been moderated, we may resort with much advantage to the stimulating expectorants. ACUTE BRONCHITIS. 335 R.—G. ammonia? 51. Infusio. polygal. seneg. 5 viij. Oxymel. Scill. gi.—M. ft. S. , A tablespoonful every two hours for an adult. When the pulse becomes very small and weak, some of fche more active stimulants should be exhibited along with the expectorants. For this purpose, camphor and the carbonate of ammonia are valu- able. I have used the following mixtures with much benefit in cases of this kind : R.—Pul. camph. Qii, ----g.Arab. 3d Syrup Scillae 5 i. Triturate them in a mortar, then gradually add, Aq. fontansG, §vi. Tinct. opii. gtt. lx.—M. S. Take a tablespoonful every hour or two. Or, R.—Carbon, ammoniae gii. Extract, glycyrrh. §ss. Aq. fontanae ^viij. Acid, scillse ^ss.—M. S. Take a tablespoonful every hour or two. In instances of this kind, Hoffman declares, that the following com- bination has often, in his hands, afforded complete relief in cases ap- parently hopeless : R.—Flor. benzoes gr. iv. P. camphor gr. ii. Sacchar. alb. Qi.—M. This dose to be taken every two hours* Opium cannot in general be given with propriety in this affection, after the bronchial secretion is fully established. By its tendency to suspend for a time the efforts to expectorate, it may readily give rise to dangerous accumulations of mucus in the bronchial tubes. When the cough is dry, however, and the arterial reaction has been mode- rated by depletion, the judicious employment of this narcotic will often procure much relief. "In combination with small doses of calomel, opium may sometimes be beneficially exhibited at an early period of the disease. WThen conjoined, these remedies not only di- minish the cough, and assist expectoration, but seem likewise to regu- late the secretion in adults." (Hastings.) In the bronchitis of old people, I have given opium and calomel in the proportion of half a grain of the former to two grains of the latter, every three or four hours, with much benefit in the early period of the disease. In very young children, however, opium is always to be used with the great- est caution. External irritating applications to the thorax are highly import- ant means in the cure of this disease. Immediately after blood has been efficiently abstracted, a blister should be applied over the ante- * Richter's Specielle Therapie, b. i, p. 424. 336 CHRONIC BRONCHITIS. rior surface of the chest, and the surface kept discharging, by some irritating ointment. In children, much benefit usually results from the application of leeches to the chest after general bleeding. Leech- ing, indeed, constitutes a primary remedy in this affection, and ought always,.if possible, to be practised. In many instances, I have known immediate and very great relief obtained from the local abstraction of blood in this way. A large emollient poultice should be applied after the leeches have been removed ; or a blister may be laid over the breast, and suffered to remain until the skin is inflamed, and then replaced by a poultice. The warm bath may also be used with a good effect, where the skin is dry and harsh. A regulated temperature of the atmosphere in the patient's cham- ber is of no small degree of importance in the management of this disease. The air of the room should be kept comfortably and uni- formly warm, so as to favour the action of the cutaneous exhalents.* Low or sudden variations of temperature are extremely apt to have a prejudicial influence in this affection. During the debility, which generally remains after the disease has been subdued, benefit will often be derived from mild and nourishing diet, and the use of weak infusions of colomba, gentian, &c. Sect. V. — Chronic Bronchitis.—Bronchial Consumption. Chronic inflammation of the mucous membrane of the bronchia, is an affection of very frequent occurrence in cold and variable cli- mates. In its simplest form it constitutes those protracted catarrhal affections which are common during winter in old persons, and in such as are predisposed to pneumonic irritation. Cases of this kind generally commence with the cold weather, and continue to the end of winter. They are characterized by a troublesome cough, attended with copious expectoration of a viscid muco-purulent, or a whitish frothy matter; uneasy and somewhat oppressed respiration, accom- panied at times with wheezing ; more or less weight and uneasiness in the epigastrium ; loss of appetite ; a slightly furred tongue ; irregu- lar action of the bowels ; a quick and irritated pulse, particularly to- wards evening; and deep red and scanty urine. The coughing usually occurs in fits of considerable violence, being generally most severe in the morning on arising from bed, or on passing from a warm to a cold air. Sudden atmospheric vicissitudes, also, seldom fail to increase the violence and frequency of the spells of coughing; and the same effect is usually produced by the inhalation of irritating vapours, fine dust, smoke, and occasionally by the act of swallowing food. Slight transient pains are, at times, felt in the chest; frequently, however, no painful sensations whatever are experienced, except immediately after a fit of cotfghing, when a general aching pain is felt for a few moments in the breast. There is another variety of chronic bronchitis, which, in its general * Broussais, Histoire des Phlegmasies Chroniques, torn, i, p. 149. CHRONIC BRONCHITIS. 337 phenomena and effects upon the system, bears so close a resemblance to tubercular phthisis, that it is not unfrequently mistaken for this latter affection—and which is described by authors, under the name of Catarrhal Consumption. A large portion of the cases usually regarded as true tuberculous consumption, consists of instances of chronic bronchitis; and as a correct diagnosis between these two affections is of much practical consequence, it is especially important that particular attention be paid to the distinctive phenomena and pathological conditions of the present malady. This, as well as the former variety of bronchitis, is the con- sequence generally of neglected catarrh ; and it occurs occasionally as the result of an acute attack of bronchial inflammation. At first, the symptoms resemble those of ordinary catarrh—the expectoration u being viscid, thick, and opaque, but not yellow, containing small lamps of a firm or viscid, grayish, translucent mucus, which sink in water. Mixed with these sputa, we sometimes find small membra- nous or flaky substances, which float on the surface of water. (Hast- ings.) As the disease advances, this viscid mucus becomes more and more mixed with a yellowish opaque fluid, resembling pus, and often slightly streaked with blood. In many instances, the expectoration, at last, acquires a whitish opaque appearance, resembling cream, and sometimes a uniformly greenish-yellow colour, which readily sinks in water. At first, the pulse becomes slightly accelerated and tense towards evening; and the heat of the surface varies in the course of the day, being sometimes above, and, at others, below the natural standard. Partial sweats, about the head and breast, occur during the night. The thirst is generally considerably increased ; the urine is high-coloured, and deposits a copious reddish sediment on cooling. A sense of soreness in the chest, with an occasional transient stitch ':'r. in the side, is felt in the majority of instances; but there is rarely any ' fixed pain in the thorax. The cough is usually severe—particularly : on rising out of bed in the morning, at which time the respiration is more or less wheezing, accompanied with a feeling of tightness in "! the breast. If the disease continue unchecked in its course, the ex- 1 pectoration becomes at last purulent and extremely copious. Debility s- and emaciation proceed rapidly, and the difficulty of breathing, and ,: sense of weight and tightness across the chest, become more and more ,s distressing. The pulse is now generally very frequent, being seldom !! under one hundred and twenty in a minute. In the early part of the **■ day the face is usually pale, but a deep flush on one or both cheeks $ is commonly observed during the evening febrile exacerbations. The # tongue becomes clean, and in many instances " it assumes a shining >*"■ appearance, and is redder than in health." Profuse and exhausting # night-sweats generally occur at this advanced stage of the disease ; fj; and towards the termination of fatal cases, colliquative diarrhoea, and oedema of the ankles, supervene as in tubercular phthisis pulmonalis. f Indeed, in the latter stages of the disease, it is generally difficult, if vol. I.—22 338 CHRONIC BRONCHITIS. not impossible, to distinguish it with certainty from tubercular con- sumption ; nor is it less fatal in its tendency after it has advanced to this stage, than genuine pulmonary consumption. When chronic bronchitis is complicated with hepatic disease, an occurrence by no means uncommon, it forms what authors have termed "dyspeptic consumption:'' IfUhis variety of the disease we have, in addition to the ordinary phenomena of chronic bronchial inflammation, various symptoms indicative of hepatic disorder—such as tenderness and tension in the epigastrium and right hypochondrium ; irregularity of the bowels with unnatural stools ; a sallow hue of the skin, and yel- lowness of the conjunctiva; flatulency ; indigestion, with variable appetite; increased dyspnoea, and cough after taking hearty meals; furred and brown tongue; foul breath; and occasional nausea or vomiting. In some instances of this variety of bronchitis, no symp- toms indicative of pulmonic affection occur in the commencement of the malady, the only manifestations of disease being such as are usually present in liver affections. A dull pain or tenderness in the right hy- pochondrium, with increased uneasiness by lying on the left side; irregularity of the bowels; foul tongue, and depression of spirits, are, in such cases, the first symptoms complained of by the patient. " The first warnings of disease in the bronchial membrane are slight. There is a dry cough, unattended with any pain. By degrees the cough becomes more" troublesome, and when it continues for some time, a tenacious mucus is expectorated. The breathing, too, is in some de- gree affected, and the patient complains of weight and tightness across the chest." The bronchial affection now advances with more or less celerity, until a copious purulent expectoration, and the usual symp- toms of hectic, are fully established.* Diagnosis. — The following diagnostic circumstances between chronic bronchitis, in the early period of its course, and tubercular phthisis, will, in general, enable us to distinguish these two affectiorils from each other. In chronic bronchitis the face is generally pallid, and the lips of a bluish hue. In tubercular phthisis the lips are red, and the cheeks more constantly flushed. " In the beginning of chronic inflammation of the bronchia, the hands and feet are often cold, and the temperature of the surface altogether more variable than in tu- bercular consumption." More or less inflammation and soreness usually occur in the upper portion of the pharynx, during the early period of chronic bronchitis, which is very rarely the case in tuber- cular phthisis. In the former affection the expectoration is free almost from the commencement, and continues to be blended with a large portion of transparent viscid mucus to the end of the disease.t In * A Treatise on Inflammation of the Mucous Membrane of the Lungs, &c. By Charles Hastings, M. D., p. 277. f " Early in the disease," says Dr. Hastings, " the absence of pain during in- spiration ; the capability of jesting on either side in bed, (when there is no abdo- minal disease;) the wheezing noise in respiration; the leaden colour of the lips, and the pallidity of the countenance; the appearance of the sputa, consisting almost entirely of mucus, occasionally streaked with blood, are symptoms suffi- CHRONIC BRONCHITIS. 339 tubercular consumption, on the other hand, the cough is for a long time short-and dry. Chronic bronchitis is attended with much more oppression in the chest, and wheezing respiration, though less pec- toral pain, than true pulmonary phthisis.* The paroxysms of hectic fever are much less regular in chronic bronchitis than in tubercu- lar phthisis. Besides these diagnostic indications, the presence or absence of the ordinary signs of a scrofulous habit, as well as the ori- gin and general progress of the disease, will, in general, aid us con- siderably in discriminating these two affections. In its commencement and early stage, chronic bronchitis is usually much more distinctly inflammatory than scrofulous phthisis. It should be remarked, how- ever, that these two forms of pulmonary disease may exist simulta- neously ; and phthisis pulmonalis is, in fact, not unfrequently associ- ated, in its advanced periods, with chronic mucous inflammation of the bronchia. Post-mortem appearances.—On opening the thorax the lungs do not collapse; the capillaries of the mucous membrane are dilated and strongly injected, giving, in some instances, an appearance to this membrane, as if it were composed of a congeries of vessels. (Hast- ings.) This membrane is generally considerably thickened, and in many cases it is found ulcerated in different parts of its extent. The bronchial cells are usually much engorged with purulent matter, mixed with a bloody serous fluid, and a portion of frothy mucus. In some cases the bronchial membrane is covered with numerous minute pimples or eminences, bearing some resemblance to pustules. (Arm- strong.) Sometimes the inflammation is found to have extended from the mucous membrane to the surrounding cellular and pulmonary structures; and sometimes the submucous cellular texture exhibits only a state of redness and vascular congestion; whilst in other instances, this structure is condensed and elastic by the deposition of lymph into its interstices. When the inflammation has extended to the substance of the lungs, we usually find it somewhat hard and dense, with loss of its natural elasticity and compressibility. (Badham.) In some cases the pleura is thickly sown with minute tubercular de- positions, showing that the diseased excitement had extended itself to this membrane. Broussais states, that in the fatal cases of chronic bronchitis among the soldiers of the French army, induration of the substance of the lungs was almost a universal pathological pheno- menon ;t and he ascribes the great frequency of this disorganized state of the pulmonary structure to the exposure of the soldiers to wet and inclement weather, while in a state of debility and privation. He states that more or less extensive portions of the parenchymatous substance of the lungs were almost always found in a state of red hepatization, interspersed with softened and broken-down parts, as if putrefaction had taken place in these points. ciently well-marked to distinguish chronic inflammation of the bronchia from tubercular phthisis."—Loco citat., p. 290. * Dr. Armstrong on Consumption, &c. t Phlegmasies Chroniques, torn, i, p. 144. 340 CHRONIC BRONCHITIS. Causes.—Chronic inflammation of the mucous membrane of the bronchia may occur as the sequel of acute bronchitis. Most com- monly, however, it arises from neglected catarrh. It is the conse- quence sometimes of measles ; of hepatic disease; and of protracted disorder primarily located in the digestive organs. It may also pro- ceed directly from the influence of atmospheric inclemency and vicis- situdes of temperature ; and from the inhalation of irritating vapours or particles of matter floating in the atmosphere—a common source of the disease among stone-cutters, needle-grinders, millers, &c. It occasionally occurs, also, in consequence of hooping-cough—particu- larly from taking cold while under the influence of this affection. Treatment.—The principal indications to be kept in view in the treatment of chronic inflammation of the mucous membrane of the bronchia, are :—1, to diminish the morbid excitability and excitement of the sanguiferous system; 2, to lessen the determination to, and derive the circulation from, the inflamed mucous structure of the lungs; and 3, to correct the functional derangement of the skin, liver, and alimentary canal. In the early stage of the disease, the activity of the pulse will some- times call for moderate general bleeding; but this evacuation can seldom be often repeated, even in moderate quantities, without the risk of doing injury by its tendency to increase the general irritability and weakness which attend this affection. Where the general phlo- gistic excitement indicates the propriety of bleeding, it will always, perhaps, be better to trust to occasional leeching or cupping. After the disease has assumed the character of phthisis, the abstraction of blood may be regarded as very generally altogether improper. From the intimate sympathetic relation which subsists between the skin and the lining membrane of the bronchia, it is of great import- ance in the treatment of this affection, to keep up a regular action of the cutaneous exhalents; for, in proportion as we increase the acti- vity of these emunctories, so do we, in general, lessen the afflux of the fluids to the lungs. For this purpose, the patient should be di- rected to wear flannel next the skin, and to protect himself by pro- per clothing against the influence of cold and atmospheric vicissitudes. An equable and mild temperature will generally contribute greatly to the successful management of this disease. No remedial treatment can procure a permanent advantage in this complaint, when the pa- tient is much exposed to a damp, variable, and inclement atmosphere. If the patient's situation or circumstances do not admit of his visiting warm and uniform climates, he should remain in his chamber—the air of which must be kept at a comfortable and regular temperature, during the cold and variable seasons of the year. When the weather is mild, exercise in the open air will, in general, prove salutary in this affection. External irritating applications to the breast, are among our most useful means for combating this disease. Blisters may be employed for this purpose; but pustulation by frictions with tartar emetic, or white precipitate ointment, will produce a more permanent, and, in general, a more efficient counter-irritation. Setons, or caustic issues, CHRONIC BRONCHITIS. 341 are much recommended by some writers; but their good effects are not equal, I think, to those which may be derived from more exten- sive irritation. Broussais recommends the application of large emol- lient poultices over the breast. He asserts, that he has cured inveterate cases of catarrhal inflammation by the continued use of poultices of this kind. They are to be preferred to blisters, he says, in nervous irritable, and plethoric patients. I have myself known great benefit to be derived in delicate and nervous persons affected with this dis- ease from emollient poultices to the breast. After the skin has been pustulated by tartar emetic ointment, poultices of this kind should be kept applied over the breast until the pustules are entirely" healed In the milder variety of chronic bronchitis described above—that is' in those chronic catarrhal affections which are apt to occur in old per- sons during the winter, mild emetics have been found useful by dis- lodging the viscid secretions with which the bronchial cells become engorged: but their beneficial effects are generally only palliative To moderate the general irritability of the system, and the velocity of the circulation, digitalis may be advantageously employed, iii the advanced stages of the disease, when the expectoration has ac- quired a purulent character, I have known considerable benefit to be obtained from the use of digitalis and tinct. of the balsam of tolu according to the following formula : R.—Tinct. digitalis gss. '-----tolutani l'i.—M. S. Take a teaspoonful three times daily. At an earlier period of the disease, small doses of digitalis in union with pulvis antimonialis, will sometimes prove serviceable, by less- ening the momentum of the circulation, and sustaining the regular action of the cutaneous exhalents. Dr. Hastings speaks very favourably of the effects of squills in the advanced stage of this complaint—more especially in those cases which assume the character of chronic cough. I have used this article, in combination with the seed of phelandrium aquaticum, with much benefit in a considerable number of cases. I usuallv orderitthus: 3 R.—Sem. phelandr. aquat. giss. Pulv. scillae gr. xii. Pulv. opii gr. ii.—M. Divide into eight equal parts. S. Take one three times daily. The phelandrium is much extolled by some German writers as a remedy in this disease. The use of the tincture of colchicum is recommended by some in the treatment of this affection. Hastings observes that he has found it to allay the cough, promote the expectoration and flow of urine, and keep up a regular action of the bowels. It may be used, he says, where squills, from their greater tendency to excite the sangui- ferous system, are inadmissible. From twenty to thirty drops may be given three times daily. I have, in a few instances, known this medicine, in union with the tincture of belladonna, to produce ex- cellent effects in this disease. Twenty drops of the former may be given with from thirty to forty drops of the latter thrice a day. 342 CHRONIC BRONCHITIS. Some of the vegetable balsams have of late years been particularly recommended in chronic inflammation of the bronchia. Of these, the balsam copaiva is decidedly the most useful. Dr. Armstrong observes, that this article « seems, in many cases, to exert a specific influence over the mucous membrane of the trachea and its branches; it increases the flow of urine ; generally keeps the bowels regularly open, and sometimes excites a peculiar itching of the skin. At first, it should be given in doses of from thirty to forty drops three times a day, and gradually increased afterwards to sixty or eighty drops at each dose." I have myself used this article with prominent bene- fit in the advanced periods of the disease; but in many instances, little or no apparent benefit resulted from its use; and, in a few cases, it was evidently injurious, both by weakening the tone of the digestive organs, and by increasing the general febrile irritation. Morgagni employed this balsam in conjunction with sulphur in chronic catarrhal affections; and Armstrong asserts that he has given this combination with unequivocal advantage in the present disease. 1 have usually given the balsam according to this formula: R.—Sodae supercarbonat. giss. Vitel. ovor.No. iii. Sacch. albi ^ss. Bals. copaib. sjvi. Aq. fontanae ^viij. Tinct. opii gtt. lx.—M. S. Take a tablespoonful three times daily. Armstrong has found an emulsion of the spirits of turpentine very efficacious in this disease; but its powers are too irritating to admit of employment in the ordinary cases of the disease. The Peruvian bark has been found a useful remedy in this affec- tion, when the night-sweats are profuse and the general debility considerable. Given with diluted sulphuric acid in such cases, its beneficial effects, says Dr. Hastings, are sometimes very evident. It tends to restrain the debilitating night-sweats, and " to alter the secretion from the mucous membrane of the lungs." In chronic bronchitis succeeding hooping-cough, I have used the sulphate of quinine with marked advantage. In several instances of this kind, I gave this article, in union with the extract of conium, with the happiest effect. Opium is often decidedly beneficial in this disease. Given in combination with ipecacuanha, or in the form of Dover's powder, it always procures great temporary relief, and may materially assist other remedies in the reduction of the bronchial inflammation. It is inadmissible, however, so long as there is much febrile irritation; but in the advanced period of the disease, particularly in the chronic bronchial inflammation of old or debilitated subjects, where the sys- tem is irritable and the cough frequent and troublesome, six to eight grains of Dover's powder, given in the evening, will suspend the cough and procure comfortable rest during the night. The extract of conium or hyoscyamus with ipecacuanha, may also be usefully employed, for the purpose of allaying the general irritability and CHRONIC BRONCHITIS. 343 cough, and improving the character of the expectoration. The same intentions will, in general, be answered by full doses of lactucarium. This article is particularly recommended by Dr. Duncan, in the management of pulmonary affections. It may be used with benefit in instances where opium, from its constipating effects, or other dis- agreeable consequences, is inadmissible. The dose is from two to three grains. The prussic acid has been employed with benefit in this affection. From its powerful tendency to reduce the general excitability of the system, it is, without doubt, well calculated to do good in this com- plaint. Its variable and dangerous activity, however, renders it an extremely precarious and hazardous remedy. I have known a few instances in which considerable relief was obtained from this medi- cine; but in the majority of cases no advantage was derived from it, and in two it produced alarming prostration. It may be given accord- ing to this formula :* R.—Acid, hydrocyanic! gtt. viij. Mucilag. g. Arab. 3*ss. Sacch. albi ^ij. Aq. fontanae 3 viij.—M. S. Take a tablespoonful every three or four hours. In the first edition of this work, I omitted, through inadvertence, mentioning the sugar of lead as a remedy in chronic bronchitis, attended with hectic. From my own experience with this article, I am entirely persuaded, that it will more generally afford relief in this affection, than any other remedy we possess. When the expectora- tion is copious, and the night-sweats profuse, it rarely fails to mode- rate and improve the former, and to check the latter evacuation. In most instances, too, it exerts a manifest controlling influence over the febrile irritation. Indeed, I am persuaded, that the powers of the sugar of lead as a remedy in this form of consumption, are not sufficiently known to the profession in this country. In Germany it has long since been Used by many eminent practitioners, as a favour- ite remedy in this affection. Osiander speaks in the most favourable terms of its powers in this respect. He asserts that it is not only an excellent and prompt palliative, but the most certain means for effect- ing a cure we possess \ Hildebrandt also strongly recommends its use in this disease. There is a very remarkable case of what is called blennorrhoea pulmonum related in Horn's Archives, which was radically cured by the internal use of this remedy. J In France, M. Fouquier has been long in the habit of prescribing this article in consumption, and his confidence in its salutary powers appears to be very great. He asserts that the sugar of lead may be regarded as a specific remedy for the profuse night-sweats of hectic. It must be * The deleterious effects of the prussic acid may be speedily counteracted by a full dose of the aq. ammonia, or of a solution of the carbonate of ammonia. t Osiander, Entwickelungskrankeiten des weiblichen geschlechts. X Archiv. d. Pract. Med., b. 4, hf. 2, s. 287. 344 CHRONIC BRONCHITIS. observed, that although a valuable means for checking the copious sweats in every variety of consumption, the sugar of lead cannot be expected to procure any permanent or radical benefit, or effect a cure in tuberculous phthisis, or in any form of this disease attended with structural lesion of the lungs. In that variety of consumptive dis- ease, however, which depends solely on chronic inflammation of the mucous membrane of the lungs—and in which the expectoration of puruloid matter is generally very copious, a well-regulated use of this remedy not unfrequently contributes very greatly to the com- plete restoration of health. Within the present year, I succeeded in curing a case of this kind—attended with all the usual symptoms of fully-developed phthisis, in a child about five years old, by the use of the sugar of lead. This case was the consequence of hooping- cough—a disease which not unfrequently terminates in chronic bronchitis. The best mode of using this article, in the present affec- tion, is to give it in union with Dover's powder, or with the extract of hyoscyamus. One grain of the lead with four grains of Dover's powder, or two grains of the extract of hyoscyamus, should be given three times daily. The quantity of the lead must be gradually in- creased, until it amounts to three or four grains at each dose. It is a fact, pretty generally known, that the sugar of lead very rarely produces colic. Osiander declares that in the course of thirty years' practice, during Which he prescribed it in several hundred cases, it never gave rise to any injurious consequences.* The inner bark of the ampelopsis hedra has been employed with great advantage in the advanced stage of chronic bronchitis. It is given in decoction, in the proportion of an ounce of the bark to a pint of boiling water—of which a wineglassful is to be taken four times daily.t In a single instance in which 1 have lately used this article, I obtained marked benefit from it. The cough gradually declined, the expectoration became improved and diminished, and the general irritation of the vascular system subdued. The bark of the while willow, in the form of powder, formed into an electuary with sulphur and honey, was employed with much suc- cess by Dr. Kerckhoff, in the last stage of consumption from chronic inflammation of the mucous membrane of the bronchia.}: The root of the actea racemosa has been employed by some American physi- cians in chronic pulmonary affections. I have had some experience with this article in the treatment of chronic inflammation of the mucous membrane of the lungs; and its effects have appeared to me beneficial in several instances. I have found it to diminish the velocity of the circulation, and to render the expectoration less copious and of a more natural appearance. It is given in decoction in the proportion of an ounce of the root to a pint of water. A table- spoonful of it is to be taken every four hours during the day. Its * Casper's Characteristik der Franzosischen Medicin., p. 239. t See Dr. Atkin's paper in the Philadelphia Med. and Surg. Journal, October, 1826. t Transact, of Lond. College of Physicians, vol. vi. CHRONIC BRONCHITIS. 345 operation is slow, and requires protracted use to obtain any particular advantage from it. When chronic bronchitis is complicated with hepatic disease, mer- cury must be used in conjunction with the other remedies employed for the bronchial affection. Small doses of blue pill should be given until the gums are very slightly inflamed ; and this degree of mer- curial action must be sustained so long as there is any tenderness in the right hypochondriac or hypogastric regions, and the alvine evacu- ations indicate deficient or vitiated biliary secretion. I have usedi the following pill with peculiar benefit in this modification of the . disease: R.—Massae hydrarg. 3L ■ Aloes soccot. Qi. Tart, antimonii gr. iij.—M. Divide into thirty pills. Take one every morning and evening. In some instances, calomel will agree much better with the sto- mach than the blue pill—the latter giving rise to general irritation and more or less gastric disturbance. When calomel is used, it should be given in very small doses, and may be advantageously combined with the extract of conium. Sulphur was formerly much employed in chronic pulmonary affections of this kind. In chronic catarrh, attended with a puru- loid expectoration, I have known much benefit derived from Engle- hard's mixture.* Of late years a great deal has been said of the inhalation of the fumes of tar, in the treatment of chronic inflammation of the mucous membrane of the lungs. That this remedy has been employed with some success in this complaint, the testimony published by men of eminence and respectability does not permit us to doubt. It appears to be now generally admitted, however, that its powers are by no means so salutary as was first asserted. Hastings states "that in chronic bronchitis, the inhalation of tar-fumes seems to assist other remedies in restoring the mucous membrane to its healthy secretion ; and in some very obstinate cases, the inhalation alone has appeared r to remove the diseased action in the mucous membrane of the lungs. In other instances, the inflammation has been aggravated and ren- "., dered acute by it. When the habit of the body is irritable, and the inflammation at all active, the symptoms are increased by its use; but if the disease has been long in a chronic state, and the habit of body not irritable, relief may be expected from it." I have employed ' this remedy in perhaps a dozen cases; in a few instances, I found it particularly beneficial, though generally it failed to do any good whatever. The fumes of resin have also been recommended in the present complaint. A few pieces may be thrown upon hot coals on * R.—Extract, hyoscyam. Flor. sulph. Extract, glycyrrh. aa 31.—M. Of this mixture eight grains are to be taken three times dady. 346 PHTHISIS PULMONALIS. a shovel, and brought near the patient, so as to cause him to inhale the fumes. The tar is used by placing it in a dish over hot coals, and suffering it to evaporate slowly, until the air of the patient's chamber is well impregnated with the fumes. If the cough and dyspnoea are aggravated by these inhalations, which frequently hap- pens, they must be discontinued. The inhalation of powdered vegetable substances, dispersed in the air breathed by the patient, has been used with marked benefit in the phthisical stage of chronic bronchial inflammation. Dr. Darwin mentions the inhalation of the dust of cinchona as having afforded relief in chronic pulmonary complaints. I have known the inhala- tion of the dust of oak bark effect a complete cure in an instance of chronic bronchitis. Sect. VI.—Phthisis Pulmonalis. Pulmonary Consumption. The assemblage of morbid phenomena, usually designated by the term consumption, may arise from various pathological conditions of the respiratory organs, which, in a practical point of view, it is of much consequence to discriminate from each other. Thus, the symptoms by which physicians are in the habit of recognizing the presence of consumption may depend: 1. On chronic inflammation of the mucous membrane of the bronchia; 2. On ulceration and chronic inflammation of the larynx or trachea; 3. Chronic inflam- mation of the pleura; 4. Inflammation and the formation of vomica, or abscesses in the parenchymatous substance of the lungs; 5. Ul- ceration of hepatized lungs; 6. Ulceration with melanosis; 7. Infarc- tion of the lungs with morbid cartilaginoid granulations; and, 8. Softening of tuberculous matter in the lungs, with more or less chronic inflammation and disorganization of the pulmonary tissue. Of the first of these varieties of pulmonary disease, I have already treated in the preceding section, under the head of chronic bronchitis; and this, the catarrhal or pituitous consumption of authors, consti- tutes, probably, the majority of the reputed cases of phthisis pul- monalis in cold and variable climates. 1. Laryngeal and tracheal Consumption.—Ulceration of the larynx or trachea gives rise to what is termed laryngeal or tracheal consumption, a variety of phthisis which is generally rapid in its course, and always of a most fatal tendency. Tracheal and laryngeal consumption usually begins with a slight tickling cough; and obscure feeling of uneasiness or pain in some part of the trachea or larynx; occasional oppression of breathing, and slight febrile irritation in the evening. One of the first and most con- stant symptoms of this variety of the disease is a change of the voice; which becomes indistinct, hoarse, feeble, and whispering. The patient is apt to feel and press the larynx or trachea with his fingers. When the larynx is the seat of the local affection, the first words in the PHTHISIS PULMONALIS. 347 morning are uttered with considerable difficulty. The pain in the larynx or trachea, is always increased by coughing, external pressure, and by the inhalation of irritating vapours. When the trachea is the part affected, an increase of the pain is experienced on bending the head backwards, or on turning it round. This is not the case . when the larynx is the seat of the disease ; here the pain, as well as the cough, is increased by the use of stimulating gargles, and the inspiration of cold and damp air. In laryngeal consumption, the cough is generally violent early in the morning, until something is expecto- rated ; and like spasmodic cough, it often subsides for a considerable time, and then returns in sudden and violent paroxysms, the inspira- tion during the fit of coughing being stridulous, as in croup. A fit of coughing is almost always excited, when the patient begins to swal- low; and it seems at first as if the cough were excited only by quick and careless swallowing; yet as the disease advances, the utmost cau- tion in this respect will not prevent this act from exciting the cough. (Armstrong.) The quantity of the sputa is not great in the laryngeal variety of the disease ; but, in tracheal phthisis it is often abundant, consisting chiefly of a viscid, transparent, and frothy mucus, with small masses of purulent matter floating in it. When the disease is once fully established, the usual symptoms of hectic fever occur, the body wastes rapidly, the skin becomes sallow, and the face generally pale, with a transient flush on one or both cheeks in the evening, and a peculiar haggard and anxious expression of the countenance, with an irritable and dejected state of the mind. The ordinary causes of this variety of phthisis are: neglected catarrh; hooping-cough; measles, and syphilis. Dr. Armstrong men- tions an instance, which was excited by an external tumour pressing on the windpipe. 2. Pleural Consumption.—Another variety of consumption, as is stated above, depends on effusion into the cavity of the thorax from chronic inflammation of the pleura. WTiile the effusion into the cavity of the chest is going on, the lung becomes more and more separated from the surface of the thorax, being gradually compressed by the accumulating fluid, until it is reduced to a very small size, and more or less disorganized in its structure. Whilst this is going on, ulceration sometimes takes place in some part of the pulmonary pleura, and the corresponding substance of the lung, and an opening is thus made into the bronchial tubes, through which the effused sero-purulent fluid is discharged by coughing or expectoration. When this takes place, irritative fever, with night-sweats, frequent cough, emaciation, and in short, all the ordinary symptoms of phthisis pul- monalis, usually supervene. This form of pneumonic disease is generally the consequence of acute pleuritis. This affection is cha- racterized by a sense of oppression in the cheston lying down; difficult and hurried respiration on ascending stairs, or muscular exertion; short, disturbed sleep; paucity of urine; a short, tickling cough, aggravated on first lying down; spells of hurried and oppressed breathing after speaking; and generally, more or less soreness of the external surface of the affected side of the chest. The patient is 348 PHTHISIS PULMONALIS. easiest when in a sitting posture ; and " if requested to take a deep inspiration while in the erect position, he will generally do it with little apparent difficulty; but lay him down flat, and cause him to fetch his breath deeply, he will be almost certain to complain of pain, tightness, soreness, load, or some kind of inconvenience in the chest." (Armstrong.) Death often occurs suddenly, and is almost invariably « preceded by considerable oedema of the legs and feet. In some instances, after the effused fluid is discharged through the lungs, the progress of the disease becomes arrested, and the patient recovers a tolerable state of health. When this occurs, the affected side of the thorax contracts to a very manifest degree, forming what Laennec describes under the name of contracted chest. In some instances, where ulceration establishes a communication between the bronchial cells and the cavity of the pleura, more or less of pneumothorax occurs; but more generally adhesions take place around the fistulous opening, which prevents the escape of air into the chest from becom- ing so considerable as to compress the lungs. (Laennec.) 3. Imposthumous Consumption.—Consumption from the forma- tion of an abscess in the lungs, is an extremely rare occurrence, although formely supposed to be one of the most common forms of the disease. Laennec states, as the result of his observations, that small abscesses in the pulmonary tissue are not found above four or five times, and large ones not above once in several hundred cases. He regards almost the whole of the reported cases of pulmonary abscesses of the lungs as excavations formed by the softening of tu- bercular masses. It is nevertheless probable, from the observations of others, that abscess of the lungs is not so uncommon as is asserted by Laennec. Armstrong mentions several instances of this kind, and cases are related by Morgagni, Baillie, Foubert, Wright, Heller, Lettsom, and many others. 4. Ulceration with melanosis of the substance of the lungs, is also occasionally met with in phthisis pulmonalis. I have seen one remarkable instance of this variety of phthisis, in consultation with Dr. Monges and Dr. M'Clellan. Bayle says that this form of the disease Occurs only in adults, and most commonly in persons of ad- vanced age. "The lungs of those who die of this affection, present more or less extensive ulcerations, the parietes of which are as black as charcoal, very firm, and several lines in thickness. The parts not in the immediate vicinity of these melanosed ulcers, appear to be perfectly healthy; but if the disease affects the whole lung, it is hard, compact, black, resembling sometimes leather half burned." Phthisis from melanosis is often of long duration, and seldom gives rise to any alarming symptoms until it has continued for a considera- ble time. The patient usually has a moderate cough, attended with a whitish or puruloid matter, slightly opaque, and usually in roundish masses, swimming in a considerable quantity of a thin mucus. These sputa always swim in water. There is little or no pain whatever felt in the chest; and in some cases the patient is entirely free from feelings of indisposition. Nevertheless, the body gradually wastes; the pulse is generally somewhat more frequent than natural, and PHTHISIS PULMONALIS. 349 occasionally, the cough excites vomiting. At last the emaciation usually becomes extremely great, although the patient seldom com- plains of much illness or uneasy sensations. Very considerable oedema of the legs is a common occurrence towards the conclusion of the malady. 5. Cancerous Consumption.—The substance of the lungs is liable to a species of cancerous degeneration, giving rise to a slow and most fatal variety of phthisis pulmonalis. Fortunately, however, this is a very rare variety of pulmonary disease. When the cancerous masses are insulated, there are, in general, many of them throughout the lungs; but the surrounding pulmonary structure is usually in nearly a healthy state. " When, however, the cancerous masses are not insulated, different portions of the lungs, and, occasionally, some of the bronchial glands, are transformed into a white substance, evi- dently of a cancerous character, belonging, in fact, to that variety of cancer designated by M. Laennec under the name of degCnerescence cerebriform. The diseased parts are white, somewhat shining, some- times of a firm consistence, and at others already softened, and always traversed by extremely small blood-vessels. When the softened parts are compressed, a liquid matter issues from a great number of points, bearing a strong resemblance to cream. This degeneration pursues the same course that.other cancerous affections do, and resembles much in its intimate structure the cancerous masses which are some- times developed in the liver, as well as the alterations which occur in the mucous membrane of the stomach, when this organ is affected with scirrhus." (Bayle.) The progress of cancerous consumption is very slow. At first, the respiration is somewhat obstructed, attended with a dry cough, which is rarely very troublesome. As the disease advances, the patient begins to feel some pectoral oppression, the cough becomes more troublesome, and the patient experiences, at times, transient pains in the chest. These pains gradually become more frequent and prolonged until they are constant, at the same time that the cough becomes less dry, and a more or less abundant expectoration of white matter ensues. The skin is usually of a pale yellow colour. This affection, says Bayle, seldom if ever occurs in persons under thirty years of age, and the majority of those who labour under it are at the same time affected with cancerous tumours in other parts of the body.* 6. Granular Consumption.—In some cases of phthisis, the lungs contain an immense number of transparent, shining, miliary granu- lations. These granulations vary in size from that of a millet seed to that of a grain of wheat, and appear to be of a cartilaginous consist- ence. Mr. Bayle thinks that they differ entirely from miliary tuber- cles, which latter, he says, are always gray, or white and opaque, and terminate by complete softening. The miliary granulations, generally, at last, give rise to ulceration of the pulmonary parenchyma, and when this takes place, the ulcerated cavity is always found lined with an albuminoid membraniform substance.t * Recherches sur la Phthisie Pulmonaire. Par G. L. Bayle, p. 36. t Loco citat., p. 37. 350 PHTHISIS PULMONALIS. 7. Tubercular or scrofulous Phthisis*—This is a most fatal aud unmanageable form of pulmonary consumption. In the commence- ment of the disease, slight aching pains, with a sense of tension or tightness, is experienced in some part of the chest, together with a short and dry cough, which is readily excited by muscular exertions. Respiration is shorter and more frequent, and deep inspiration is usually attended with a feeling of uneasiness and tightness in a par- ticular part of the breast. These symptoms gradually become more conspicuous; and at length slight febrile irritation occurs towards evening, and the pulse and respiration continue to be somewhat accelerated throughout the whole day. A fit of coughing usually occurs in the morning, and the patient rises out of bed in a relaxed, languid, and feeble condition. An extreme liability to catarrh, on the slightest exposure to cold and damp air, exists. The bowels are usually somewhat torpid; the tongue is moist, often clean, and of a pale pink-colour, or covered with a thin white fur. By degrees the cough becomes more frequent and troublesome—particularly in the evening and morning, or at night on awaking from sleep. Great sensibility to low temperature is manifested by the patient. As the disease advances, the albuginea acquires a peculiar pearly whiteness; the skin, lips, tongue, and fauces, become dry in the afternoon, slight chills regularly occur about midday, followed by distinct febrile exa- cerbations, during which one or both cheeks are suffused with a cir- cumscribed flush; a dry and burning heat is felt in the palms of the hands and the soles of the feet; the breathing is very quick and short, and the pulse very frequent, small, quick, and tense. These febrile paroxysms continue until towards midnight, when they terminate in more or less profuse perspiration, which continues till morning, leav- ing the patient exhausted, languid, and depressed. Previous to the occurrence of these latter irritative phenomena, the expectoration, which at first was scanty and frothy, becomes thicker and purulent, and occasionally streaked with blood. By degrees the sputa assume more and more the character of genuine pus; the evening exacerba- tions become more distinct, the night-sweats more profuse; the burn- ing in the palms of the hands and soles of the feet more distressing; the cough more frequent and violent; and emaciation makes evident progress, attended with increasing failure of strength—in short, hectic fever is now completely developed—the pulse being seldom less than 130 during the evening exacerbations, although generally languid, weak, soft, and not much above its natural frequency in the morning. Towards the unfavourable termination of the disease, oedema of the * [In the first volume of his recent and admirable publications, Dr. Chapman maintains the position that tubercles and scrofula are essentially different in their characters. He decides that the deposits of true phthisis partake of the ma- lignancy of cancerous and other morbid and intractable growths. Dr. Elliotson appears to countenance the same idea, and dissents from the opinion of Laennec, that tubercular cavities are occasionally cicatrized. Andral has also formed the same opinion in regard to the imaginary cicatrices on the surface of the lungs.— Mc] PHTHISIS PULMONALIS. 351 feet, and colliquative diarrhoea, almost invariably come on, accom- panied with a weak and hoarse voice, often aphthae in the fauces, difficulty of swallowing, and sometimes ulcerated throat. The mind generally^continues to be unaffected to the last; but injome instances, <• a degree of languid delirium occurs for some Hays, and occasionally.^ ■ToTaTlmbecflity for a week'pfevToiislocTeanVy "It is a femarkahle circumstance, that pulmonary consumption is very generally suspended in its progress by pregnancy. I have met with five or six instances of this kind. As soon as the delivery of the child has taken place, the consumptive symptoms resume their force, and generally advance with rapidity to a fatal termination. It is_ equally remarkable that the symptoms of pulrnjDimj^ con- sumption occasibria fly; though indeed very "rarely, alternate with mama. I am at this time attending a young lady in the "Iasl"stage"of 'j^hthTsisi^Ho_ has Jo r fo u r months past been in a'sfate of continued mental derangement. She complains of no pectoral uneasiness, and does not appear to be conscious of labouring under this disease ; al- though her body is now extremely emaciated, and she coughs almost continually, and has a copious purulent expectoration. Dr. Storer* has published some interesting observations on the con- version of phthisis pulmonalis info inflammation of the braim The cerebral affection usuallyiTommehces with headache, which gradually mTFeases, whilst the consumptive symptoms disappear pari passu, ^J untiTdelirium and finally fatal coma ensue. From one of the casesc'1 which he has published, it would appear, that by subduing the dis- ease of the brain, we may frequently put a permanent stop to the pulmonary affection. Dn Abercrombie, also, has related several highly interesting cases"oFlnania, alnoHbtEeFTorms of acute cerebral "^ilection^sup^erveTimg "oh phthisis pulmonalis, with the speedy cessa- tion of the symptoms of this affection.f Similar instances are men- tioned by Dr. Parry.f _Tubercular^consumption probably never occurs, except in individu- als of a strumous diathesis*;§~and TfTs doubtful, as Dr. Armstrong * Transactions of the Medico-Chirurg. Society of Edinburgh, vol. iii, part 2, p. 613. t See his work on the Brain, &c, cases 29, 45, 55, 56 and 57. X Elements of Pathology and Therapeutics, p. 385 and 388. § Tubercles are, I believe, never found in the lungs of still-born children, or of such as die soon after birth. Dr. Denis, Eleve Interne, at the Hospital of Enfans Trouves at Paris, declares, " Ou n'a pas encore trouve jusqu'ici de tubercules pul- monaires avant le premiers mois que suivent la naissance. Ou commence seul- ment k les rencontrer dans des enfans de 5 ou 6 mois." (a) Velpeau, also, states that he has never found any tubercular depositions in a new-born infants, though he has long directed his attention to this subject; and Brechet. who is surgeon to the Hospital Enfans Trouves, at Paris; makes the same declaration. Orfila, how- ever, states that he has in a very few instances met with tubercles in still-born infants. ' ___________ (a) Recherches d'Anatomie et de Physiologie Pathologiques sur plusieurs ma- ladies des Enfans nouveau-nes.—Par M. Denis, M. D. .--■---■,.• . ----------;—y— 352 - PHTHISIS PULMONALIS. . - ■ -/ > observes, whether tubercular matter be ever formed in the Jungs with- out a constitutional or hereditary predisposition to them. Tie this as it may, it appears to be well ascertained, that wherev^r^hjsjpredis- "" position does exist, ajry__cailse which is capable of irritating theftfngs_ " may give rise to the.depositionV tubercular matter into^theh^sub-^ " stance, andlead, consequently, to the development of phthisis puTrno- nalis. It has, however, been a subject of considerable coiTtToTersy, whether inflammation is capable of causing the deposition of tuber- cular matter into the lungs. Bayle, Laennec, Rostan, Louis, and Velpeau, are disposed to allow but little or no influence to inflamma- tion in this respect; whilst Alison, Andral, Cruveilhier, and Broussais maintain that inflammation is frequently intimately concerned in the , production of tubercular matter. The following observations>_oiJfi ■>;- - /Andral, on this subject, are probably correct: "If the disposition to"" " the formation of tubercles is very strong, then the slightest "locaTcom "' gestion of blood is sufficient to give occasion to it; if this disposition "~lsrtess strong, it is requisite, for the formation of tubercular matter, that the congestion of blood should be so considerable, and so per- manent, as to amount to" inflammation. But, when there exists no such predisposition, the most intense and the longest continued inflarh- mation, will not.produce a'tubercle."* Tubercular""matter would seem to be formed by a kind of exudation or secretion into the pul- monary tissue ; and as it appears to be unorganized, may be regarded as an extraneous substance, obstructing the pulmonary circulation, and giving rise to more or less local irritation. Tubercular deposinojis^ in_the lungs do not, however, inevitably lead to''consumption^ for it_ would seem "lb be well ascertained, that tubercles may exist in the * pulmonary structure in a dormant state—that is, without entering info"" ' "the process of softening"; Of exciting inffammation—-and without giving^ rise either to local inconvenience, or general disturbance oFTiealth. (Armstrong, Laennec.) In individuals of a scrofulous habit, the for- mation of tubercles is sometimes very rapid, when pulmonary irrita- tion is excited by any accidental irritating cause. In the beginning, tubercles have the appearance of semitransparent grains ; and as they gradually increase in size, they become united into regular masses, and assume a yellowish and opaque appearance. M. Laennec asserts, that the conversion of the tubercular matter into a soft pus-like fluid, is not effected in a manner similar to what takes place in suppurative inflammation ; but by a peculiar process of softening, wholly distinct from suppuration. The softening commences in the centre of the tubercle, and gradually proceeds outwards, until the whole mass is converted into a whitish, cream-like matter, which, making its way into the bronchial tubes, is discharged by expectoration, leaving a kind of fistulous cavity. These tubercular excavations, become lined with " a species of morbid membrane, of a white and opaque appearance, and very soft consistence ; external to which, another membrane of a semi-cartilaginous structure is formed. Bayle thinks, that the pus, expectorated in scrofulous consumption, is secreted chiefly by the * Clinique Medicale, t. iii, p. 13. PHTHISIS PULMONALIS. 353 lining membrane of the tubercular cavities; but Laennec asserts, that the greater part of the purulent matter expectorated proceeds from the mucous membrane of the bronchia, which always suffers irrita- tion and chronic inflammation, to a greater or less extent, in every variety of pulmonary consumption. Purulent expectoration from this source occurs in some instances of tubercular lungs, even before the tubercles have undergone the process of softening. Every case of tubercular phthisis consists therefore of at least two, and some- times three, simultaneous processes : viz., 1, "the proper tubercular action either in a state of growth or increase, or in that of softening or destruction; 2, of a degree of chronic inflammation of the mu- cous membrane of the bronchia; and 3, sometimes of inflammation of the pulmonic tissue, of a chronic character, and tending to hepa- tization." Causes.—As has already been stated, persons may be decidedly predisposed to phthisis, and ^ven affected with a tubercular state of the lungs, and yet_escape the disease, if no adequate exciting cause 'supervene to rouse it into action. In some instances, functional or organic diseases of the liver develop the disease where the predis- position to it exists. Catarrhal affections, however, are by far the most common exciting causes of the disease. The tubercles may also be excited into action by a fixed irritation located in any of the principal viscera, more especially in the alimentary canal. Repelled cutaneous eruptions have a strong tendency to develop the tubercu- lar action, as indeed all other morbid impressions on the skin have in subjects of a phthisical habit. The sympathy between the external surface and the lungs is intimate and strong, and an irritation seated in the former seldom fails to manifest itself in the latter organ—more especially when the lungs are in a state of habitual debility or pre- disposition to morbid action. It is on this account that phthisis pul- monalis is so common a disease in cold and variable climates, where the cutaneous function is so liable to sudden and frequent interrup- tions or variations of activity. Among the ordinary exciting causes of this affection, we may also mention the healing up of old discharg- ing sores; atmospheric vicissitudes; the abuse of mercury; intempe- rance in the use of spirituous liquors; sedentary occupations; excessive venereal indulgence, and onanism; copious losses of blood; the de- pressing passions; the admission of irritating vapours or fine particles into the lungs—to which the latter cause, stone-cutters, glass-grinders, millers, needle-grinders, &c, are particularly exposed. Prognosis.—The different varieties of pulmonary disease men- tioned above, vary very considerably in the degree of sanability, peculiar to them respectively. That form of consumptive disease, which depends upon chronic bronchial inflammation, is by far the most under the control of judicious remedial treatment; and where the mucous tissue remains free from ulceration, or the subjacent pulmonic structure has not become consolidated, recoveries are by no means uncommon. Laryngeal and tracheal consumptions are extremely dangerous affections. I have never known an instance of recovery from this vol. i.—23 354 PHTHISIS PULMONALIS. variety of the disease. Cases of recovery have, however, been re- lated by authors, but the number of such instances is very limited. Consumption from chronic pleuritis, is much more difficult of cure than that which depends on chronic inflammation of the mucous membrane of the lungs; yet in some instances, the disease subsides, and the patient regains a considerable degree of health. When a cure is effected, the effused fluid is either gradually absorbed while the lungs expand, or it is discharged through the lungs by an open- ing into the bronchial tubes from the cavity of the pleura, or it escapes externally by an opening into the cavity of the chest through the in- tercostal spaces. Tubercular consumption maybe regarded as an incurable dis- ease ; for tubercular matter, so far as we know, is wholly incapable "of being absorbed or otherwise removed. " Previously to the know- ledge of the true character and mode of development of tubercles," says Laennec, " and while consumption was considered as a conse- quence of chronic inflammation, and slow suppuration of the pulmo- nary tissue, medical men did not question the possibility of curing this disease by a suitable mode of treatment, especially if taken in time, and during the first stage. It is now, however, the general opinion of all those who are acquainted with "the actual state of our "knowledge respecting the" pathology of oTiseases£that the tubercular" affection, like cancer, is absolutely incurable, inasmuch as nature's "efforts towards effecting a cure are injurious, and those of art use- less." However impossible it may be to remove tubercular matter when once formed, or to cure consumption depending on it, there can exist no doubt that we may occasionally so retard, or even arrest its progress by proper management, as to prolong life to a very con- siderable extent. Nay, it is equally certain, that by carefully avoid- ing those causes which tend to favour the conversion of tubercular matter into a pus-like fluid, persons who are manifestly strumous, or affected with incipient tubercles in the lungs, may pass through a long life without the actual development of consumptive symptoms. Although tubercular consumption maybe regarded as incurable by_^ art, "yet in some fare cases a spontaneous cure has taken place_after_ the softening of the tubercular matter and the "fmroatibirbf an ulcer- ous excavation. Laennec, upon whose authority this statement is made, mentions two cases which termmatedJayourably in this wajE, Such cures, he says, are effected in two ways; 1, by the"cavity be- coming invested by a new membrane of a semi-cartilaginous struc- ture, which, when completely formed, constitutes a kind of internal cicatrix, analogous to a fistula, and " is, in many cases, not more in- jurious to health than this species of morbid affection;" 2, the cure may also be effected by a spontaneous obliteration of the cavity by a cicatrix consisting of cellular, fibrous, or cartilaginous structure. Such cures are, however, extremely rare, and depend in no manner on medical treatment. (Laennec.) Treatment. — Of the treatment appropriate to catarrhal consump- tion, I have already spoken fully, under the head of chronic bronchitis, and the subsequent therapeutic observations refer chiefly to tubercular PHTHISIS PULMONALIS. 355 phthisis. Notwithstanding the uncontrollable and fatal character of tubercular consumption when once fully developed, patients labour- ing under this form of disease are not to be abandoned to their fate, without making an effort to arrest, or at least to retard its progress; for although the hope of curing the malady, after its complete estab- lishment, is wholly fallacious, experience has fully demonstrated the fact, that, by judicious management, we may often keep the tubercles in a dormant state, interrupt their progress, or at least greatly retard their passage into an active condition. In consumptive habits, every thing which tends to irritate the system, more especially the respiratory organs, should be carefully avoided. Attention ought, above all, to be directed to the regular maintenance of the perspiratory function; and with this view, the patient should be directed to wear flannel next his skin; to protect himself by proper clothing against the influence of low temperature ; and to avoid, as much as his cir- cumstances may admit, the effects of atmospheric vicissitudes. In the incipient stage of every variety of pulmonary consumption, our constant object should be to counteract the inflammatory diathesis of the system, and to remove all sources of irritation. The regimen must be strictly antiphlogistic. In general, vegetable and farinaceous diet, with milk, is the only proper nourishment for a patient labour- ing under incipient phthisis. The system, in all phthisical habits, is peculiarly excitable, and readily thrown into a state of general and injurious irritation by even weak exciting causes. It would be in vain to expect a reduction of the local pulmonary irritation, so long as the system generally is in a state of preternatural excitation. In conjunction with a mild, unirritating diet, the wearing of flannel next the skin, and the careful avoidance of inclement and variable weather, gentle exercise, either by walking, riding on horseback, or in an open carriage, when the air is mild and uniform, will tend to invigorate the system, and lessen its morbid irritability. Bleeding is highly recommended by some in the early period of phthisis pulmonalis ; and when cautiously employed in cases attended with an evident, inflammatory condition of the general system, its effects are often beneficial. To draw blood copiously, or very fre- quently, however, would, in most instances, prove injurious by in- creasing the debility and morbid excitability of the system. The abstraction of blood by cupping or leeching, in cases which indicate the propriety of direct depletion, will in general answer all the pur- poses which can be expected from this measure. To expect to effect the permanent reduction of the quickness, tension, and fre- quency of the pulse by venesection, is a fallacious hope. The sys- tem in this disease is preternaturally excitable or irritable; and in order to reduce the velocity and momentum of the circulation, measures must be employed which tend to subdue this morbid irritability, an effect which cannot be obtained from venesection. To accomplish this purpose, we possess no remedies which are so safe and so effectual as digitalis, and small doses of tartar emetic. The former of these articles has a powerful tendency to diminish the excitability of the heart and arteries, and consequently the velocity of the circulation. 356 PHTHISIS PULMONALIS. Much diversity of opinion has been expressed in relation to the value of this medicine in consumptive affections. My own observations have led me to the conviction, that under careful management, and in conjunction with a well-regulated diet, and proper attention to the cutaneous functions, much good may be derived from its employment in incipient phthisis. Its salutary operation would seem to depend on its power of lessening the activity of the heart and arteries, and thereby moderating the momentum of the circulation, and conse- quently the general and local irritated condition of the disease Among the most important remedies we possess in the early periods of phthisis, are such as operate through the medium of the skin, or such as establish a regular determination to the external surface of the body. Blisters, issues, or setons, can never be properly omitted in incipient consumption. I have repeatedly known the insertion of a caustic issue or a seton on the chest, to remove every symptom of approaching consumption. Even in cases completely developed, counter-irritation, in any of these modes, will generally aid very materially in retarding the progress of the malady. I am disposed to ascribe more remedial^power in this affection to setons and issues than to blistering, and of these two, I generally prefer the latter. Pustulation with tartar emetic, or with the white precipitate oint- ment, is also a very efficient mode of counter-irritation in this dis- ease. I have seen much benefit derived from both these applications in its incipient stage. When the pustules are formed, emollient poultices should be applied to them, and renewed two or three times daily, until they are healed. Whatever counter-irritating measure be adopted, it should be regularly persevered in, until all the threat- ening symptoms have entirely disappeared, or its manifest efficiency be ascertained. To aid the effects of flannel next the skin, and of a warm and equable temperature in maintaining a regular action of the cutaneous exhalents, advantage may be derived from the use of small portions of tartar emetic dissolved in some mild diluent beverage, in the commencement of the disease. A grain or a grain and a half of this antimonial may be dissolved in a pint of gum arable water, and drank during the day. M. Lenthois, of Montpellier, speaks strongly in favour of this remedy in phthisis. His mode of employing it is as follows:—A grain of tartar emetic is to be dissolved in eight tablespoonfuls of water ; this is to be mixed with four quarts of water, or a tablespoonful to the pint, which the patient is directed to use for his common drink at meals, and at all seasons and hours. Dr. Armstrong directs the use of this article in doses sufficiently large to excite nausea and occasional vomiting. " I suspect," he says, " that if a regulated temperature and the exhibition of tartarized antimony were more early and perseveringly employed than they usually are, our success in preventing the development of phthisis might be much greater than it commonly is." The account which Lenthois gives of the usefulness of tart, antim. in the present affec- tion is certainly exaggerated; but, although not perhaps of itself sufficient to arrest the progress of incipient phthisis, it deserves, PHTHISIS PULMONALIS. 357 nevertheless, very considerable attention as an auxiliary means. The employment of emetics in this disease was formerly much recommended by some writers. Dr. Maryatt gave the sulphate of copper and tartar emetic in doses of from two to five grains of the former with two grains of the latter twice a week, without allowing the patient any kind of drink for several hours afterwards. Dr. Senter advises to give the blue vitriol in conjunction with ipecacu- anha (seven grains of each), in the morning before receiving any thing into the stomach, and withholding all kinds of drink for some time afterwards. Unquestionably, however, the most efficient of all measures for counteracting the tendency to phthisis, or arresting its development or progress, is a removal to, and residence in, a mild, genial, uniform, and salubrious climate. The influence of such an _ atmosphere, aided by proper diet, regular and gentle exercise, and external revulsives, with an attention to the hepatic and intestinal functions, will do all, perhaps, that remedial treatment is capable of effecting towards permanently arresting the progress of the disease in its incipient stage. The climates of Naples, of Nice, of Florence and of Rome, and lately of Egypt, as well as of some of the south- ern parts of France and Spain, have been particularly recommended to consumptive invalids. Nothing, however, is to be expected from the influence of a warm climate after the disease is once fully de- veloped. It is only in the incipient stage of the complaint that any permanent advantages can be obtained from this source, in scrofu- lous phthisis.* Upon the foregoing remedial measures—namely, occasional small bleedings, external irritating applications, antimonials, a regulated temperature, a simple unirritating diet, and exercise by walking or gestation, our hopes must be mainly placed in our efforts to arrest the disease in its incipient stage. A variety of other remedies have, however, been recommended in this affection ; and of these prussic acid has of late years attracted the greatest attention. Could the dose be regulated with any degree of certainty, so as to procure its influence without the risk of dangerous prostration, advantage might, no doubt, be derived from its employment. Possessing, as it does, a direct and most powerful tendency to subdue the irritability and sensibility of the system, it would seem to be peculiarly calculated to do good in the present affection, in which a particularly excitable condition is so conspicuous. When the disease is once completely established, and purulent expectoration with hectic fever has supervened, we can no longer hope to procure a favourable issue by remedial management; and all our efforts must be directed "to the palliation of the symptoms and the prolongation of its course. With the exception of depletion, the remedies already mentioned as most apt to arrest incipient con- * See Dr. Carter's " Remarks upon the Effects of a Warm Climate in Pulmo- nary Consumption and some other diseases."—Medico-Chir urg. Transact., vol. vi._See, also, Medical History of the British army in Spain.- -Medico-Chirurg. Transact., vol. vi. 358 PHTHISIS PULMONALIS. sumption or prevent its development, are also among the most useful means in retarding its progress when fully established. When the system is much exhausted in the confirmed stage of the disease, tonics are commonly resorted to, but although I have tried them often in scrofulous phthisis, I do not remember having ever derived any obvious advantage from them—but most commonly they in- creased the general irritation.'1* Where it becomes necessary to sup- port the strength of the system, we may allow a more nourishing diet, particularly the more digestible and nourishing kinds of meat- such as tender beef-steak or mutton. To check the profuse and exhausting night-sweats which occur in the advanced periods of the disease, I know of no remedy which is so effectual as the acetate of lead. I have frequently prescribed this article with unequivocal benefit in this respect. Four or five grains of the acetate may be taken in the evening. I have known some patients who, after having experienced the relief which it frequently procures, would not do without it. The best mode of giving it is in union with opium. Some of the mineral acids are also recom- mended for this purpose. Of these, the diluted sulphuric acid, or elixir of vitriol is the best. Opium is a highly valuable palliative in the advanced stage of phthisis. It generally allays, for a time, the violence and frequency of the cough; tends to diminish the night-sweats, as well as the general feelings of distress, illness, and discomfort; and, at last, assuages the pangs of approaching disso- lution by its soothing and oblivious effects on the nervous system. W7hen opium produces disagreeable effects from idiosyncrasy, the lactucarium may be used in two or three grain doses with excellent effect. We may also employ Dover's powder in union with the extract of hyoscyamus as an anodyne palliative, where opium by itself is objectionable. Six grains of the former, with three grains of the latter, may be given every night. Dr. Bourne, professor of the practice of physic in the University of Oxford, speaks strongly in favour of the employment of uva ursi in consumption. He asserts that he cured nine cases out of sixteen by the use of ten grains of uva ursi with one-third of a grain of opium three times daily. In consumptive symptoms from chronic bronchitis, I have derived much benefit from these two articles given in combi- nation ; and the cases related by Mr. Bourne were probably of this kind.t Expectorants are sometimes useful to palliate the cough. Flax- seed-tea, decoction of the lichen Icelandicus, solution of gum Arabic, infusion of tussilago or of marshmallows the camphorated tincture of * The tonics most commonly employed in phthisis pulmonalis, are the mistura fern compos., the quinine, and particularly Dr.Griffith's mixture,—thus: R. Myrrh. 3i. terendo mortario cum spirit, piment. gvi. aq. distil, ^viss. dein adde subcar- bon. potassse, 3ss. sulphat. ferri. gr. xii. syrup, gii.—M. Take 3d. four times daily. t Cases of Consumption, &c, healed by uva ursi, &c. By Dr. Bourne, London, 1806. PHTHISIS PULMONALIS. 359 opium, and syrup of squills in equal proportions, or syrup of poppies with tincture of tolutan, may be used for this purpose. Small doses of opium and tartar emetic, as recommended by Pariset, will gene- rally answer very well.* The inhalation of tar-fumes is not adapted to the treatment of tubercular consumption. In the catarrhal variety of the disease, much benefit may be occasionally derived from this and similar inhalations. Nor is mercury a remedy calculated to do good in the present form of phthisis, although much recommended by some prac- titioners. The cases of consumption which are reported as having yifided to ptyalism were, no doubt, dependent on chronic mucous inflammation, unconnected with a strumous habit of tubercles in the lungs. Too little discrimination was formerly made between the different varieties of pulmonary disease attended with consumptive symptoms; and it is to this circumstance that we may ascribe the discordant and contradictory statements that have been published in relation to the effects of different remedies and modes of treatment. Laryngeal and tracheal phthisis appear frequently to commence with an obscure inflammation in some parts of the larynx or trachea, which may continue for months before ulceration occurs. This inci- pient stage is characterized by more or less hoarseness, change of voice, and disturbed respiration; and it is only during this early period of the disease, before ulceration has taken place, that any decided and permanent benefit can be derived from remedial treatment. Whenever, therefore, we find hoarseness of voice, with cough, dis- turbed respiration, and a slight prickling pain in the larynx or trachea to continue for some time, particularly when there is no reason to ascribe these symptoms to common cold, we ought im- mediately to adopt the most active measures for the removal of the affection. Should ulceration not have taken place, we may, perhaps, succeed in preventing it, and in saving the life of the patient. (Arm- strong.) One of the most indispensable curative means is a mild and uniform temperature. On no account should the patient be suffered to expose himself to a cold or humid atmosphere. While these pre- cautions are observed, blisters should be applied to the throat, and the blistered surface kept discharging by irritating dressings. Arm- strong recommends the use of balsam copaiba in the early stage of this variety of the disease. In several cases which have lately come under my care, the use of the muriate of ammonia, according to the formula mentioned at page 127 of this work, appeared to do much good. When the disease arises from syphilis, mercury may be regarded as the principal remedy in conjunction with a regulated temperature and blistering. In consumptive symptoms from chronic pleuritis, our principal re- liance must be placed on external irritating applications to the chest, * R.—G. opii gr. x. Tart, antim. gr. iv. Conserv. rosar. q. s.—M. Divide into forty pdls. S. Take one every four hours. 360 NEPHRITIS. the use of calomel so as to produce gentle ptyalism, and diuretic medicines. Blisters or tartar emetic ointment should be repeatedly applied so as to keep up a constant irritation on the external surface of the chest. Internally, we may give calomel and squills in combi- nation, with a view both to a general mercurial impression and the production of diuresis. CHAPTER XIII. OF THE PHLEGMASIA OF THE URINARY AND GENITAL ORGANS. Sect. I.—Nephritis.—Inflammation of the Kidneys. The symptoms which characterize acute inflammation of the kid- neys, are not in general obscure or equivocal—being usually readily distinguished from those of other painful affections seated in the neigh- bourhood of these organs. When this affection is excited by cold, it commences commonly like other diseases from this cause, by slight chills and flushes of heat—the febrile reaction preceding the occur- rence of pain in the loins. When the disease proceeds from contusions, strains, and irritation of renal calculi, cantharides, or other irritating substances absorbed into the circulation, or from metastasis of gout and rheumatism, the first intimation of its occurrence is an acute pressing pain in the right or left lumbar region, or in both. The pain* is deep-seated, and of a very severe aching character, and but very little aggravated by external pressure. Any sudden concussive motion of the body, however, always increases the pain considerably. The pain often darts down along the ureters—the testicle of the affected side is retracted towards the abdominal ring, and a sense of numbness is experienced in the thigh. Nausea and vomiting occur in most cases, and violent colic pains in some. The bowels are torpid; the urine is very small in quantity, high-coloured, sometimes tinged with blood; and the desire to void it is frequent, urgent, and trouble- some. When both kidneys are inflamed, the secretion of urine is generally almost entirely suppressed;—this, indeed, happens some- times when the inflammation is seated but in one kidney, the other having its functions disturbed sympathetically.! The patient is easiest * M. Bouillaud asserts, contrary to the general statement of pathologists, that pain does not always attend renal inflammation. f This is always a very unfavourable occurrence. Total or almost entire sup- pression of the urinary secretion can never continue long in any affeetion with- out adding greatly to the danger of the disease. Complete ischuria renalis, even without the irritation of local inflammation, seldom continues beyond four or five days without producing fatal oppression of the brain.—(Sir H. Halford, Trans- NEPHRITIS. 361 when he inclines his body towards the affected side, so as to take off the tension of the lumbar muscles. When in bed, he lies either on the affected side or on the back, with the body inclined towards this side. In some instances, a dull heavy pain is at first felt low down, seemingly where the ureters enter the bladder^and afterwards passes slowly up along the ureter until it reaches the kidney, where it be- comes stationary. The pulse in nephritis is full, hard, and frequent in the early period of the affection; but after the second or third day, it generally becomes smaller and more frequent, particularly where much nausea and vomiting occur. The surface is above the' natural standard of temperature, and usually very dry and parched. Diagnosis.—From inflammation of the psoas muscle, nephritis may be distinguished by the pain in the former affection being always con- siderably increased on bending the body forwards, whereas, in the latter disease, this position generally lessens the pain. Nephritis is usually attended with more or less nausea and vomiting, and frequent desire to pass off urine, which is not the case in psoas inflammation, unless the kidneys become affected at the same time. From lumbago, nephritis is distinguished by the paucity of the urine, the dysury, the nausea and vomiting, the pain shooting down the ureters in the latter affection; and by the great increase of pain on assuming the erect position, or by any motion of the muscles of the loins in the former, whilst in the latter, little or no increase of pain occurs from these causes. Nephritis is generally rapid in its course. It seldom continues beyond the seventh day without terminating in resolution or tending to suppuration. When the disease is about terminating favourably by resolution, the fever and pain decline; the skin becomes uniformly moist; the urine is copious, turbid, or charged with mucus; and the nausea and vomiting cease.* The symptoms which denote occur- rence of^uppuration are—frequent chills or shiverings; a dull, heavy throbbing, instead of the preceding acute pain in the kidney; a slight abatement of the febrile symptoms ; and a feeling of heaviness or numbness in the affected part. In some instances, the abscess bursts into the pelvis of the kidneys, and is then discharged with the urine. This is not so favourable an occurrence as might at first sight appear. I have known purulent matter discharged with the urine for upwards of nine months, from a renal abscess. In some instances, more or less pus is discharged with the urine for several years—producing at last hectic and great actions of the College of Physicians of London, vol. vi.) There is a case men- tioned, however, by Dr. Laing, in vol. x. of the Edin. Med. and Surg. Journal, where the secretion of urine was suspended for nine days without terminating fatally. The great danger from suppression of this secretion in nephritis, was long ago noticed by Aretseus.—De Causis et signis Morborum, acut., lib. ii, cap. ix, p. 22. * Actius says that a watery and pellucid urine indicates a slow and difficult declension of the disease—" aquosse autem mictiones. et purse ac pellucentes aegre morbum secerni indicant."—Scrmo xi, cap. xvi. 362 NEPHRITIS. emaciation, or what has been called tabes renalis. A puruloid sub- stance in the urine must not, however, be too hastily pronounced as the result of renal suppuration, or as genuine pus. The irritation of a calculous concretion in the kidneys will sometimes give rise to a secretion resembling pus ; and the same discharge may occur from subacute inflammation of the neck of the bladder. Genuine pus in the urine may generally be distinguished from a puruloid fluid mixed with this secretion, by the former sinking down and forming a thin uniform layer along the bottom of the vessel in which the urine is left standing ; whereas, the latter substance remains partly suspended in the urine, and does not settle down into a close layer along the bottom of the vessel.* In some cases, the abscess points externally, and may be evacuated by an incision into the soft fluctuating tumour. Cases are on record which terminated favourably after the matter had obtained exit in this way; but in many instances of this kind, a fistulous opening remains, which it is always extremely difficult and sometimes im- possible to heal—the patient gradually sinking under symptoms of hectic.t Authors mention instances of renal abscesses having opened into the intestines; and Richter states that the matter has found its way into the liver, and even into the cavity of the thorax.J Renal abscess has also been known to burst into the cavity of the abdo- men, giving rise to rapid and fatal peritonitis,§ and instances have occurred in which the matter has passed down along the psoas muscle, and pointed at the upper part of the thigh like psoas abscess. Inflammation of the kidneys, occasionally, though rarely, termi- nates in gangrene. Scirrhus, or induration of the kidneys, also, sometimes results from this affection. Bonetus relates several exam- ples of this kind.I) M. Bouillaud mentions a change of the parenchy- matous substance of the kidneys into a tuberculous or encephaloid matter, as the result of renal inflammation ; and in several cases he found the structure of this organ converted into a yellowish seba- ceous matter.1T Causes.—From the intimate relation which exists between the kidneys and the skin, cold becomes a very frequent cause of this affection. In many instances, it arises from causes acting directly upon the kidneys—such as irritating diuretics, cantharides, turpen- tine, renal calculi or gravel, contusions, strains, &c; and in persons * Van Swieten observes, when the matter comes from the bladder, there is dis- charged with the urine a sort of foliaceous fragments; but when it proceeds from suppuration in the kidneys, it is more uniformly mixed with the urine.—Commeni., vol. x, p. 38. t Hie autem morbus molestus est ex eoque plures ad renum tabem deveniunt. Hippocrates, De Intern. Affect., cap. xvi. t Specielle Therapie, b. i, p. 615. $ Vogel. Handb.. t. iv, p. 398.—Richter, Sp. Therap. II Sepulchret. Anat., torn- ii—as quoted by Morgagni. ^Observations on the Anatomy and Diseases of the Kidneys, &c. By J. Boudlaud.—Journal Complementaire. t NEPHRITIS. 363 subject to gout or rheumatism, the disease sometimes occurs-, rapidly and violently, in consequence of metastasis of these affections. Treatment.—As in all other phlegmasial affections, prompt and efficient blood-letting constitutes the primary remedy in this disease. In addition to general bleeding, leeching, or what appears to be better, cupping over the lumbar region must not be neglected. Active pur- gatives also assist materially in reducing the local inflammation. Six or eight grains of calomel, followed in three or four hours by a full dose of castor oil, or three or four pills of the formula given below, will generally answer this purpose well.* The bowels must be kept in a loose state by the daily administration of aperients; or by laxa- tive enemata throughout the whole course of the disease. Much relief will sometimes be obtained from anodyne emollient injections, particularly in the evening, after the free operation of a purgative. Indeed, the assiduous employment of soothing emollient enemata, either with or without laudanum, is always a most useful auxiliary in the treatment of this affection. For this purpose we may use an infusion of flaxseed, or simply warm water mixed with a portion of milk; or a thin decoction of barley. Fomentations to the external lumbar region will likewise be proper, particularly in the early period of the disease, immediately after leeching or cupping has been prac- tised. A large emollient poultice is a more convenient, and probably a better application for this purpose. Blisters are very generally regarded as objectionable in this affection, on account of the tendency of cantharides to irritate the urinary organs when absorbed into the circulation. I have nevertheless derived decided benefit from blister- ing the region of the inflamed kidney, without having ever known any injurious consequences resulting from it. By suffering the vesi- catory to remain no longer than is necessary to inflame the skin— which is seldom more than four or five hours, and then applying an emollient poultice, a full blister will be raised; and I have never known strangury to occur where this mode of vesicating was adopted. I have pursued this practice in ten or twelve cases of nephritis, and generally with evident advantage. Sinapisms may also be used, after adequate depletion, with a prospect of benefit; but they are not equal, in efficacy, to blisters, in this as in other internal inflammations. From the close sympathy which exists between the skin and the kidneys, considerable benefit usually arises from the employment of suitable diaphoretics in this affection. Where the stomach is not too irritable, antimonialst may be employed; but where much nausea * H.—Extract, colocynth. compos. Qi. Calomel, gr. xii.—M. Divide into six pills. t R— Spir. nit. dulc. |i. Vin. antimonii 3d. Tinct. opii gr. xxx.—M. S. Take a teaspoonful every hour or two. Or,—R.—Spirit, mindereri %iv. Tart, antimonii gr. i. Spir. nit. dulc. 3d. Syrup limonis gii. Tinct. opii gtt. xxx.—M. S. Take a tablespoonful every two hours. 364 NEPHRITIS. and vomiting attend, it will be better to depend on the use of the warm bath, more especially the steam bath, for the production of diaphoresis. Hot bricks wrapped in flannels previously moistened with vinegar and water, and laid under the bed-coverings near the patient's body, seldom fail to bring on a more or less copious and uniform perspiration. The nitrate of potash cannot be used with propriety in nephritis, on account of its tendency to excite the activity of the kidneys, an effect which could hardly fail to do mischief in the inflamed state of these organs. All stimulating diuretics, indeed, must be carefully avoided—copious draughts of mucilaginous diluents being the only proper means for promoting the urinary secretions. After the inflammatory condition of the system has been in some degree subdued by the antiphlogistic measures already mentioned, small doses of Dover's powder repeated every three or four hours, will tend to keep up a general diaphoresis, as well as to moderate the local pain and general irritable state of the system. Much relief may also be derived, after proper depletion and purging, from the occa- sional use of anodyne enemata.* • A slight sensation of pain and soreness is apt to remain in the affected kidneys for several days, and sometimes weeks, after the disease has been subdued. Here uva ursi, in conjunction with small doses of opium or Dover's powder, is the best remedy. From twenty to thirty grains of the uva ursi, with the fourth of a grain of opium, or three grains of Dover's powder, may be taken four times daily. This remedy is no less useful in cases where the inflammation has terminated in suppuration. I have known the extract of conium, with an infusion of uva ursi, to be employed in suppuration of the kidney with complete success. Three grains of the extract were taken three times daily, and a wineglassful of the infusion (one ounce of the uva ursi to a pint of water), every four hours. Minute doses of muriate of mercury with this extract,! have also been found bene- ficial in abscess of the kidneys. The use of lime water, to the ex- tent of from four to six ounces daily, has been recommended in suppuration of the kidneys. (Richter.) Decided benefit has also been derived from the balsam copaiva; but this article must be avoided as long as there is any evidence of inflammatory action present. * R.—Pulv. opii gr. ii. Mucilag. g. Arab. gss. Lactis tepefact. ^ v. Or,— R —Tinct. opii gi. Infusi. lini §vi.—M. ft. enema. This injection may be repeated two or three times daily. t R-—Muriat. hydrarg. gr. vi. Extract, conii maculat. 3iss.—M. Divide into forty-five pills. S. Take one every morning, noon and evening. CYSTITIS. 365 Sect. II.—Cystitis.—Inflammation of the Bladder. Symptoms.— Violent burning, lancinating, or throbbing pain in the region of the bladder—extending to the perineum, and in some instances to the testicles and the upper part of the thighs, attended generally with a sense of constriction in the hypogastric region. The pain is greatly increased by pressure made immediately above the pubis, and the perineum feels sore to the touch. There are frequent, but often ineffectual efforts to avoid urine, more or less strangury or dysury being usually present. The small portion of urine which passes off is deep red, and often tinged with blood. In some cases there is a constant stillicidium of urine. Nausea and vomiting, with great anxiety in the praecordia, are seldom absent in this affection. The bowels are constipated, and there is often a sensation of tenesmus, from the inflammation extending to the lower part of the rectum. The pulse is full, hard, and frequent; the skin hot and dry; the thirst urgent, and the patient is restless and dejected. If the disease con- tinues unchecked in its course, more or less swelling occurs in the loins, with increased tenderness in the hypogastrium and perineum. Some diversity occurs in the symptoms, according to the particular part of the bladder in which the inflammation chiefly exists. When the neck of the bladder is inflamed, great pain is felt in the perineum, and total retention of urine sometimes occurs, or the patient is tor- mented with dysury or incessant feelings of strangury. In this case, the introduction of a catheter or bougie causes extreme suffering. " When the posterior part of the bladder is affected, the rectum suffers more particularly, and the patient is harassed by a most distressing and constant tenesmus. Sometimes the inflammation occupies that part of the bladder in which the mouths of the ureters are situated, which thus become involved in the affection, and a suppression of urine, more or less complete, and its consequences, take place; in this case, there is commonly more or less pain and tenderness on pressure in the hypogastric region." (Prout.) Like other inflammations, cystitis terminates either in resolution, suppuration, gangrene, or induration and thickening of the coats of the bladder. Resolution, besides the abatement of the pain and fever, is attended with general and uniform diaphoresis ; a turbid and rather copious urine, passed with little or no pain; and ability to bear pres- sure on the epigastrium, and perineum. On dissection, the inner membrane of the bladder is generally found minutely injected, so as to give a uniform red appearance to the whole surface. In some instances, the inflammation is confined entirely to the internal coat; in others, it extends to the muscular tunic; and sometimes even to the peritoneal covering.* Suppuration is not a frequent termination of this affection. (Rich- ter.) Abatement of the violence of the fever and pain, accompanied with chills or rigors, and the sudden appearance of a white matter in * Wilson on the Urinary Organs, p. 297. 366 CYSTITIS. the urine, indicate the occurrence of suppuration. In some instances, abscesses are formed in the coats of the bladder, particularly near its neck; and in others, the abscess forms in the cellular structure sur- rounding the neck of the bladder. When suppuration occurs in the mucous membrane, or when the abscess between the tunics of the bladder bursts into its cavity, the matter will be discharged with the urine. Sometimes the abscess points externally, and may open into the rectum or vagina, or ^sink down and infiltrate into the cellular membrane of the pelvis. The abscess has also been known to burst into the cavity of the peritoneum ; and the matter has made its way into the labia pudendi, and the loose structure of the scrotum. In some cases the coats of the bladder are thickened and indurated, particularly the internal one. Sometimes fungoid elevations of the mucous membrane occur; at others, indurations are found in differ- ent parts, resembling small scirrhous tumours, and some of these are occasionally ulcerated. Firm adhesions have been noticed between the bladder and rectum, as well as between the bladder and uterus, in consequence of acute cystitis. It is sometimes very difficult to dis- tinguish some of these results of inflammation of the bladder during life from calculus. Gangrene is a frequent termination of cystitis. The majority of instances that prove fatal within the first six or seven days, terminate in gangrene. The occurrence of gangrene is announced by the sudden cessation of pain; cold extremities; profuse and clammy perspiration; great prostration of strength; a cadaverous expression of the counte- nance ; slight confusion of the mind; a small, frequent, and weak pulse; and hiccough. Causes.—Cystitis may be produced by mechanical irritating sub- stances in the bladder; retained urine ; external injuries on the hypo- gastric region; irritation from acrid substances absorbed and conveyed to the bladder—as cantharides, turpentine, &c; metastasis of gout and rheumatism; irritating injections forced into the bladder; irritation from the introduction of a bougie, or catheter; gonorrhoea; suppress- ion of hemorrhoidal discharge, and of perspiration ; cold applied to the feet or lower portion of the abdomen; injury sustained in par- turition, or from the use of obstetrical instruments. Treatment.—Acute cystitis is a rapid and highly dangerous affec- tion; and must be promptly met with the most efficient antiphlogistic measures. Efficient blood-letting must be early practiced, until the activity of the pulse is moderated. After general bleeding, leeching is of the utmost importance in this affection. The leeches must be applied to the perineum, about the anus, and to the hypogastric region ; and, when the pulse admits of it, they should be reapplied. Immediately after leeching, an emollient poultice should be applied over the hypogastrium, pubis, and perineum. The bowels must be kept open, by gentle laxatives and mucilaginous enemata. Much relief is commonly obtained from an emollient anodyne enema, im- mediately after the rectum has been emptied by a laxative. Atten- tion must be early paid to the evacuation of the urine, should the bladder be found distended by it. Great care, however, is required CHRONIC CYSTITIS. 367 to avoid all unnecessary irritation from the introduction of the cathe- ter. When the neck of the bladder is inflamed, the pain caused by this operation is generally extremely severe, and it is sometimes im- possible to reach the bladder, from the great irritability and spasmo- dic contraction of its neck. This can, in some degree, be obviated by introducing three or four grains of opium into the rectum an hour before the catheter is used, accompanied with an efficient abstraction of blood, both by venesection and leeching. To promote the action of the cutaneous exhalents, we may employ the warm bath ; or, what is better, the steam bath, as mentioned under the head of nephritis. Some of the milder diaphoretics, such as spirituous mindereri, diluted with barley water or flaxseed tea; or small and frequent doses of pulvis antimonialis, or of Dover's powders, may be usefully exhibited, with a similar view. The hip-bath is particularly recommended by Richter as a local application in this affection. After the violence of the local and general inflammatory action has been moderated by the foregoing means, much benefit may sometimes be derived from the internal use of opium and calomel. Richter observes, that opium is a primary remedy in cystitis, par- ticularly when given in union with mercury. Prout also recommends the internal use of this combination. A grain of opium, with two grains of calomel, may be given every four hours. In cases of a subacute character, the employment of opium and calomel, in con- junction with leeching, emollient anodyne injections, and fomentations or poultices to the hypogastrium and perineum, is particularly bene- ficial. Nitre and blisters are apt to increase the local irritation, and cannot, therefore, be resorted to without a considerable risk of doing injury. ■<■ If blisters be employed," says Prout, " they should be used with caution and permitted to remain only for a short time, and afterwards such dressings applied.as tend to keep them open." The mode of blistering mentioned, when speaking of the treatment of nephritis, may, perhaps, be safely adopted in this affection. Con- siderable advantage is said to accrue from the repeated injection of mucilaginous fluids into the bladder, by obtunding the acrimony of the urine, and soothing irritation. Sect. III.— Chronic Cystitis. Chronic inflammation of the inner membrane of the bladder is not an uncommon affection, and is generally described under the name of ct/stirrhcea. In some instances, this affection is the consequence of acute cystitis; but it may arise, at once, from the action of the same causes which produce acute inflammation of the bladder. The symptoms which accompany chronic mucous inflammation of the bladder, are—slight lancinating pains, attended with a sense of heat or burning in the region of the bladder, and a feeling of weight and tenderness in the perineum; frequent and harassing desire to pass urine, with occasional spasmodic action of the bladder and urethra. The urine is loaded with more or less of a tenacious mucus. Slow 368 CHRONIC CYSTITIS. fever generally attends, accompanied with thirst, general debility, "particularly about the back and loins," and, in protracted cases, much emaciation and exhaustion. There is generally considerable derangement of the digestive functions; loss of appetite ; sometimes nausea and vomiting ; costiveness ; tongue covered with a white or brown fur; and the skin is harsh and dry. " In slight and incipient cases of this affection, the urine, when first passed, generally appears of a whitish colour, and is more or less opaque and turbid, with the appearance of flocculi floating through it. On standing, however, for some time, it becomes more or less transparent, and the mucus will be found together in a mass at the bottom of the vessel." (Prout.) The writer just quoted states, that in most cases the urine is acid; others assert, that it commonly exhales an ammoniacal odour, and that it is rarely acid. In some cases, the quantity of mucus dis- charged with the urine, " is enormous, amounting, occasionally, to several pints in the day; and in this case it not only comes away diffused through the urine, but also in the form of large coagula, which, by blocking up the urethra, give origin to the most distress- ing symptoms—particularly to a sense of severe burning pain along the whole course of the urethra." Sometimes this mucus is easily diffused in water of the urine: but in inveterate and violent cases, it is so extremely tenacious, as to make it very difficult to mix it with the urine. When suffered to cool, the mucus, says Prout, is sometimes so tenacious " that it may be drawn into strings of con- siderable length, and the vessel may be frequently inverted without its falling out." In the worst cases, particularly when ulceration of the inner surface of the bladder exists, copious discharges of blood, at times, take place. I have known au instance of this disease, which continued for five or six years, and at last terminated fatally, from the supervention of acute inflammation in consequence of irri- tating injections. In this case, more Or less hgemorrhage occurred from the bladder almost every month. The discharge of mucus was always very considerable. On dissection, two large ulcers of the mucous membrane were found near the neck of the bladder. Dr. M'Dowell found, in this affection, the mucous surface of the bladder to present " different degrees of vascularity, from merely a few patches of a dark or bright red colour, to an entire vascularity, in some cases so marked, as to appear as if the bladder had been daubed over with blood; the veins in general are turgid; the membrane much thickened; frequently numerous ulcers occur, covered with a tenacious brownish-coloured lymph ; these are sometimes deep and numerous, so as to give a honeycomb appearance to the membrane. The inflammation sometimes ends in complete sphacelus of the interior of the bladder."* "Blood," says Dr. M'D., "is often dis- charged in very large quantity; and, together with the abundant mucus, a white powdery sediment, or sanious matter, is mixed with the urine." This affection is most apt to occur in old and gouty subjects ; and * Dublin Transactions, vol. iv. CHRONIC CYSTITIS. 369 persons of an irritable and scrofulous ha*bit are said to be particularly predisposed to it, " more especially if they have been accustomed to free living, or been given to venereal excesses, or have suffered from these affections or gout." Treatment.—In the early stages of the complaint, we must en- deavour to reduce the chronic inflammation by local, depleting, and counter-irritating measures. Cupping along the loins, with the occa- sional application of leeches to, the perineum, and about the anus, may be accounted our most efficient remedies during the first period of the disease. If the pulse is active, and the pain in the pelvis con- siderable, general blood-letting may be very beneficially resorted to. The bowels must be kept in a relaxed state by the occasional use of gentle purgatives, such as castor oil or magnesia. I have known much benefit to result from a caustic issue on the upper and inner part of the thigh. Advantage would probably be derived also from frictions and pustulation with tartar emetic ointment on the upper part of the thighs, or on the loins. When the inflammatory symp- toms have subsided, either in consequence of the application of the remedies just stated, or by the long continuance of the disease, astringents, with some of the narcotic extracts, may be resorted to with a prospect of advantage. Dr. Prout prefers the uva ursi to all other articles of the astringent kind in this affection. " Given in combination with hyoscyamus, and steadily persevered in for a con- siderable time, the uva ursi seldom fails to diminish the irritation and quantity of mucus, and thus to mitigate the patient's sufferings." Within the last five or six years, the buchu leaves (diosma crenata) have been strongly recommended to the profession as a valuable remedy in this and other chronic affections of the bladder. * Dr. M'Dowell employed it successfully in three cases, according to the following formula: R.—Infus. buchu gvii. Tinct. ejusdem. Tinct. cubebse aa ^i.—M. S. Take an ounce of this mixture three times daily. The use of this remedy should be continued for three or four months. I have heard of the successful employment of an infusion of the pipsissewa, (chimaphila umbellata,) in a case of this disease. In several inveterate cases I have prescribed the muriated tincture of iron, with infusion of peach-leaves, with very manifest benefit. In one instance, a perfect cure was effected by the tincture of iron, in con- junction with uva ursi. Frictions over the groins and the hypogas- trium with camphorated oil have appeared to me serviceable in some cases. Besides these a great variety of other remedies have been recommended for the cure of the affection. Balsam copaiva; tur- * [It often happens that in cases of chronic cystitis, the bladder is paralyzed, or at least partially so. In such cases no relief can be afforded until a large cathe- ter is repeatedly introduced. The lower portion of the 6pine should be irritated by tartar emetic plasters, and the use of appropriate diuretics and tonics persevered in.—Mc] VOL. I.—24 370 HYSTERITIS. pentine ; balsam pern ; camphor: madder, and many of the vegeta- ble astringents, are mentioned by writers as often beneficial in this complaint. From the known good effects of balsam copaiva in chronic inflammation of mucous membranes, there is some reason to presume „that advantage might be obtained from its use in this complaint. Experience does not, however, furnish us with much testimony in its favour. I have given it in a few cases, but in these it appeared to give additional uneasiness in the bladder, without diminishing the mucous discharge. Different kinds of injections into the bladder have also been re- commended as beneficial in this affection ; such as flaxseed tea ; infu- sion of marsh-mallows; or barley-water. When retention of the urine occurs from a spasmodic constriction of the neck of the bladder, relief will often be obtained from seven or eight drops of the muri- ated tincture of iron given every half hour. The diet should be simple and digestible, and every kind of stimulating beverage care- fully avoided. Fatiguing exercise, or riding on horseback, or in a carriage over rough roads, usually aggravates the symptoms. The drink should be bland and mucilaginous. One patient under my care always felt himself much relieved by drinking the infusion of the malva rotundifolia, a common plant in this country. 1 have also prescribed the constant use of slippery elm bark tea with bene- ficial effect. Sect. IV. — Hysteritis.—Inflammation of the Womb. Acute inflammation of the uterus generally occurs in the puerperal state, and usually within a few days after parturition. Sometimes this affection commences with rigors, succeeded by fever, before any pain is experienced in the uterus ; and at others, more or less severe pain in the region of the uterus is the first intimation of its occurrence. The characteristic symptoms of the disease are : a fixed, continuous, lancinating, or a dull and aching pain in the pelvis, greatly increased by pressure or motion, and accompanied with a sense of weight, or bearing down in the perineum. The urine is generally passed with much pain and difficulty, and in some cases a total retention takes place. This is particularly apt to be the case when the anterior and lower portion of the womb is inflamed. When the inflammation is chiefly located in the posterior part of the uterus, the pain is particu- larly severe in the region of the sacrum, and the patient experiences much pain, and often tenesmus, in evacuating the bowels. Some- times the pains extend to the iliac regions, to the hips, and down the thighs to the knees, and even to the feet. When the pains extend to these parts, the lateral portions of the womb are usually the princi- pal seat of the inflammation. In the early period of the disease, little or no swelling of the abdo- men occurs, but on examining the pubic region externally with the hand, the uterus is alwaj's found considerably enlarged, firm, and exceedingly tender to the touch. In those cases that occur soon after HYSTERITIS. 371 delivery, the pain in the pelvis generally becomes much increased, at times, in consequence of the occasional contraction of the uterus, and may be mistaken for severe after-pains. To distinguish the inflammatory pains from the latter, however, it is only necessary to bear in mind that the former are always continuous, though occasion- ally aggravated, whereas the after-pains are intermitting. In the majority of instances, the system generally sympathizes strongly with the inflamed organ. In the early period of the disease, nausea, with occasional vomiting, occurs ;*— the pulse, in some cases, is full, strong, and hard ; in other instances, it is small, contracted, quick, and frequent. Severe headache is a very common attendant, and towards evening, and at night, more or less delirium usually occurs. In a great majority of cases, the lochia are entirely sup- pressed; in some instances a slight lochial discharge continues through- out the disease, and occasionally, though extremely seldom, this evacuation is even profuse. In general, the secretion of milk is some- what diminished, but it rarely becomes entirely suppressed, as in puerperal peritonitis. In some cases of hysteritis! indeed, the breasts remain full and turgid with milk, during the whole course of the dis- ease. The bowels are generally inactive, and the urine is small in quantity, of a deep red colour, and usually passed with much diffi- culty and pain. The course of hysteritis is generally rapid. If, after four or five days' continuance, it does not tend to resolution, it will most probably terminate in suppuration or gangrene. By a vigorous antiphlogistic treatment, however, the violence of the inflammation may often be broken down in the course of the first twenty-four hours, and reso- lution speedily established. When the inflammation tends to this favourable termination, the pain, tenderness, and swelling of the ute- rus abate—the pulse becomes slower, soft, and open ; the skin relaxed and moist; the tongue clean and humid ; and the headache and general uneasiness gradually disappear. The lochia, also, usually begin to flow more freely, and the urine becomes more copious and natural in its appearance. The occurrence of suppuration in the substance of the uterus is always attended with great danger. If the abscess bursts into the cavity of the peritoneum, or makes its way between this membrane and the external surface of the womb, into the cellular texture of the lower part of the pelvis, the issue will almost inevitably be fatal. Sometimes the abscess opens into the uterus, and the matter is dis- charged by the vagina. When the pus is evacuated in this way, the, probability of a favourable termination will be very considerable. I have seen an instance where the uterus abscess formed adhesions with the peritoneum in the groin, and, after three weeks, the tumour was * Dr. Dewees observes, in his account of the symptoms of this affection, that "the stomach is rarely much affected in the early pajt of the disease—at least vomiting seldom takes place." This does not accord with my own experience. In all cases of unequivocal hysteritis I have ever met with, nausea, with occa- sional retching, occurred during the early period of the malady. 372 HYSTERITIS. opened externally, and exit given to the matter. This patient finally recovered her health. Raiman states, that the abscess has, in some instances, burst into the bladder,* and cases are related, in which the matter was evacuated through the rectum. The occurrence of sup- puration may be suspected, when, after an obstinate course of the disease, for five or six days, the pains become less severe, with a feeling of weight in the affected part, at the same time that the pulse becomes more frequent, attended with occasional slight chills; irre- gular distribution of heat over the body—some parts being cool while others are hot; irregular, partial, and cool sweats; fetid, and more abundant lochia; prostration of the muscular power; dry and red tongue, and a livid flush on one or both cheeks. The termination in gangrene is not a frequent event in this affec- tion, unless the peritoneum be implicated in the inflammation. The supervention of gangrene will be readily perceived by the occurrence of the usual symptoms of mortification. A rapid cessation of the pain; great muscular prostration ; dimness of vision; a death-like counte- nance ; a profuse, cold, and clammy sweat; ice-cold extremities; and an extremely small, weak, and rapid pulse, announce the occurrence of gangrene, and the inevitable doom of the patient. The foregoing description applies to hysteritis in its simple or unmixed form—that is, inflammation of the proper substance of the uterus, without implicating its peritoneal covering in the disease. In many instances, however, the inflammation spreads to the peritoneum, an extension of the local affection frequently met with in the worst forms of what is usually called puerperal fever. Cases of this kind almost invariably prove fatal. The extension of the inflammation from the substance of the uterus to the peritoneum, is attended with an increased frequency of the pulse, tumefaction, and great tenderness of the lower part of the abdomen ; entire suppression of the lochia, "or an excessive discharge of them"—(Dewees ;) cessation of the secretion of milk; great prostration of the muscular p.owers; frequent muttering delirium; constant recumbence on the back, with the knees drawn up and raised, and the shoulders elevated, to take off the ten- sion of the abdominal muscles; a dry,coated, and brown tongue; and, towards the end, usually, diarrhoea. Cases of this kind are always rapid in their progress, and unless the inflammation be speedily sub- dued by prompt and energetic measures, collapse of the vital energies generally supervenes in forty-eight hours, and often sooner, from the time the peritoneal inflammation commences. Treatment.—The most efficient antiphlogistic means must be promptly and energetically pursued in the treatment of this affection. As soon as possible after the commencement of the inflammation, blood should be drawn from a vein to the extent of producing a very decided impression on the circulation, or an approach to syncope. If, after the first efficient bleeding, the pulse rises again, and the pain and tenderness of the parts are not materially abated, venesection should be repeated, and again to the extent of causing a very manifest re- * Handbuch der Speciellen Med. Pathologie, &c., b. i, p. 358. HYSTERITIS. 373 duction of the momentum of the circulation. When the activity of the heart and arteries has been moderated by general bleeding, and the disease is not adequately subdued, leeches should be applied,over the region of the pubes, and to the vulva and perineum. Immediately after leeching, a large emollient poultice should be applied over the lower part of the abdomen and the external organs of generation; and this application should, from time to time, be repeated, until the vio- lence of the local affection is in a great measure subdued. Dr. Dewees pbjects to the use of fomentations to the abdomen, in this affection, and asserts that they have done mischief. I have no experience with any applications of this kind, in the present malady, except emollient poultices applied after efficient venesection and leeching; and to me it has always appeared, that very evident advantage was obtained from this application. Purgatives are, in general, highly useful in hysteritis. Calomel, in doses of from eight to twelve grains, followed in the course of four hours by a full dose of Epsom or Glauber's salts, will answer this purpose very well. After the first active purgative, two or three eva- cuations should be procured daily by the exhibition of small doses of calomel and of the neutral purgative salts. Irritating purgative enemata generally aggravate the patient's sufferings, and should not be employed. I have, however, known unequivocal benefit derived from injecting into the rectum, from time to time, warm emollient fluids—such as warm water and milk—decoction of althea—infusion of flaxseed—or simply warm water. In a case which I attended about two years ago, the patient was much relieved by injections of this kind. They are particularly beneficial in the declension of the disease. Blisters are much recommended by some writers; but Dr. Dewees thinks their usefulness is very doubtful. From my own experience, I am disposed to ascribe considerable value to vesication in this affec- tion. When employed, after the momentum of the circulation has been moderated by general and local bleeding, I am well satisfied that blisters will often do much good in this complaint. If after leeching we apply an emollient poultice over the lower part of the abdomen and vulva, and blisters to the upper and internal part of the thighs, much advantage will in general result. Some benefit may also be obtained from the usual antiphlogistic diaphoretic remedies. Nitre, antimony and calomel in combination, form an excellent compound for this purpose. The muriate of am- monia, as prescribed under the head of intermitting fever, is a favour- ite remedy with many of the German physicians, and I am inclined to think that it is very worthy of attention in this respecf. Opium, in full and frequent doses, and in union with calomel, is a valuable remedy in this affection. Dr. Dewees, however, "thinks that in this, as well as in all diseases of high inflammatory action, opium is decidedly hurtful." My own experience has led me to a very different opinion. The powers of this narcotic in inflammatory affections are not as yet sufficiently appreciated. That opium is not hurtful," in all diseases of high inflammatory action," but often highly 374 CHRONIC INFLAMMATION OF THE UTERUS. beneficial, is admitted by many of the ablest practitioners of the present day. When given in active doses, and repeated so as to keep the system constantly under its full influence, it often contributes, in a powerful degree, to the reduction of the local and general phlogistic actions. By lessening the general irritability and sensibility of the system, the different organs and structures become less susceptible of the stimulus of the local inflammation, and all the sympathetic actions consequently abate in their violence; and, in like manner, by dimi- nishing the morbid sensibility, and pain of the affected part, the in- flamed capillaries will be more disposed to resume their healthy functions. Opium does not, generally, increase the momentum of the circulation, in fevers depending on local inflammation. I have frequently known, in violent cases of acute rheumatism, a full dose of opium to render the pulse less frequent, and much softer than it was before its exhibition. As this article, however, has a strong tendency to cause cephalic congestion, and may do injury in this way, where the system is plethoric, or the action of the heart and arteries very vigorous, it will always be best to delay its exhibition, until blood has been efficiently abstracted. When this has been done, and the bowels well evacuated, from one to two grains of opium, with the same quantity of calomel, may be given every three or four hours with the happiest effect in the present disease. Sect. V.—Chronic inflammation of the Uterus. Chronic inflammation of the uterus appears to be a very common affection ; and, though frequently productive of very distressing con- sequences, is often misunderstood and consequently mismanaged. This affection is frequently the result of difficult or instrumental labours; and Mr. Guilbert observes, that it often arises from excess ive venereal indulgence, and from rheumatic and gouty irritation. He mentions, also, translation of erysipelas as a frequent cause of the disease; and it supervenes occasionally, in consequence of the final cessation of the menses, at the critical period of life, and even as the result of temporary amenorrhoea. Chronic inflammation of the womb sometimes occurs in a periodical manner, and this is most apt to be the case when it arises from erysipelas. Mr. Guilbert says, that females who do not suckle their infants, are more liable to this variety of uterine disease than those who perform this interesting maternal function. Chronic inflammation sometimes affects the whole body of the uterus; but much more frequently, it is seated in the neck or mouth of this organ. Out of a hundred cases, says the author just mentioned, there will, probably, not be ten in which the inflammation is not almost exclusively seated in the neck and mouth of the womb. Many females affected in this way, either mistake their complaint, or conceal it; or from the slightness of their sufferings neglect to resort to medical aid, until serious, and often irremediable structural disease is established. Some experience only a sense of heat, with slight CHRONIC INFLAMMATION OF THE UTERUS. 375 soreness in the lower part of the pelvis ; others complain of dull or lancinating pains in the region of the womb, with occasional inter- missions and exacerbations. In some cases a sense of weight is felt, as if the uterus were prolapsed, attended with occasional pains in the upper part of the vagina. In all instances, more or less of a leucor- rhoeal discharge attends; and when, at times, the inflammation is aggravated, this discharge becomes white and opaque, or purulent. Those who are affected in this way are apt to experience considerable pain at the superior part of the vagina, during the venereal embrace ; and, in some instances, the tenderness of the os uteri is so great, that the venereal act always causes extreme suffering. On examining per vaginam, the mouth of the womb is found irre- gularly enlarged, one side or lip being usually much swollen, and very tender to the touch. So great is the sensibility of this part, that the patient experiences severe suffering from the slightest touch of the finger on making the examination. In general, the mouth of the uterus is diverted from its regular position in the vagina, and directed to one side, or sometimes to the posterior or anterior part of the pel- vis. If the disease has been of long standing, the engorgement, or swelling of the neck of the womb, is so great, as to form a large tumour embraced by the vagina. More or less pain in the back and loins occurs in nearly all cases; and the stomach usually sympathizes with the uterus, so as to give rise to a train of very harassing dyspep- tic and nervous symptoms. In some cases, the inflammation continues for years, without the occurrence of any serious structural disorder of the womb ; but in the majority of cases, the neck of this organ gradually enlarges, and becomes indurated, or scirrhous, and finally often terminates in cancerous ulceration. Many cases, that are usually regarded as simple leucorrhcea, are connected with chronic inflammation of the os uteri; and it is hence especially important, when called to prescribe for morbid vaginal discharges of a leucorrhoeal character, to ascertain, by examination, the state of the neck and mouth of the uterus. The existence of inflammation and tumefaction may be suspected, when, with a puru- loid vaginal discharge, the patient complains of heat, weight, sore- ness, or pain in the upper part of the vagina. Treatment.—When the pulse is irritated, or quick, frequent, and somewhat tense, it will, in general, be proper to draw blood from a vein—and this measure is particularly proper when the patient is of a robust and plethoric habit. The diet should be unirritating and digestible, and where the diathesis is manifestly phlogistic, the nou- rishment should be of the lightest kind, until the general irritated condition of the system is removed. When there is reason to be- lieve that the bowels are loaded with feculent matter, a few active purgatives ought to be administered in the beginning of the treat- ment ; but after the intestines have been thus thoroughly evacuated, small doses of some of the neutral purgative salts should be given two or three times a week, so as to keep up a gentle and regular action of the bowels. Much benefit is sometimes derived from the 376 CHRONIC INFLAMMATION OF THE UTERUS. application of leeches to the perinceum, and about the anus and vulva, or even to the region of the pubis. M. Guilbert, in the work referred to above, speaks in the most favourable terms of the efficacy of leeches applied to the os uteri.* He has invented a speculum uteri, by which, he says, the application of leeches to this part is very easily effected; and he has given the history of several cases, in whicii this practice was adopted with prompt and complete success. That local depletion, in this way, is likely to do much good, we cannot doubt.t In private practice, however, it would be difficult- to induce patients to submit to this treatment; and there are few practitioners, I apprehend, who would be willing even to propose this measure, unless the urgency of the case were extremely great. Cupping above the pubis, and blisters applied to the sacrum, or to the internal surface of the thighs, will sometimes contribute ma- terially to the reduction of the uterine inflammation. Some advan- tage may also be obtained from warm emollient injections into the vagina, but all astringent and exciting applications of this kind ought to be carefully avoided, with the exception, perhaps, of a very weak solution of sugar of lead.f Internally we may employ small doses of balsam copaiva, but its use must be delayed until the measures already mentioned liave, in some degree, moderated the local and general irritation. I have, in a few instances, derived considerable benefit from the internal use of the muriate of ammonia, in twenty grain doses, three times daily. When this article is dissolved in water, with a considerable portion of the extract of liquorice, it will, in general, be readily taken by patients; but without the addition of the liquorice, it is so extremely offensive to the taste, that very few are willing to employ it. If, after the inflammation, or the pain, tenderness and swelling of the neck or orifice of the womb are removed, a leucorrhoeal dis- charge continues, it must be treated according to the directions given under the head of leucorrhoea, in the second volume. * Considerations Pratiques sur les Affections de l'Uterus. Par J. N. Guilbert, M. D., &c. Paris, 1826. t [My ingenious friend and former pupil, Dr. Dodd, of the U.'S. Navy, has invented an instrument for cupping and scarifying the os uteri as well as other inter- nal parts, which promises to be exceedingly advantageous. It consists of large glass or flexible metallic tubes, containing a scarificator, and connecting with an exhausting or air-pump syringe. I have derived the greatest success, however, from the repeated application of the solid nitrate of sdver around and just within the orifice of the os tincae. The use of a speculum, although very convenient and satisfactory in extreme cases, is by no means necessary in the performance of this operation.—Mc] X The hip-bath—general warm bathing. ' Mild mercurial course, avoiding ptyalism; a few grs. of blue pill with two grs. of camphor and one-tenth tart. antimonii. PERICARDITIS. 377 CHAPTER XIV. OF THE PHLEGMASIA OF THE SANGUIFEROUS SYSTEM. Pericarditis. Inflammation of the pericardium is no very uncommon affection, and from the very important functions assigned to the parts imme- diately implicated, must be regarded as one of the most alarming and dangerous of phlegmasia! diseases. The symptoms which usually attend the acute form of the dis- ease, are—sudden severe lancinating pains in the centre or cardiac region of the chest, extending occasionally to the epigastrium, or to the back between the shoulders, attended with more or less oppress- ive dyspnoea, palpitation of the heart, and a sense of weight and con- striction under the sternum and left side of the thorax. Pain in the prsecordial region, obscurity of sound in this region on percussion, and irregularity of the pulse, are the most constant symptoms of this affec- tion. M. Louis asserts that from the concomitance of these symptoms, this affection may be recognized in about half the cases in which it occurs. In most instances the patient is entirely incapable of lying down, more especially on the left side. He is constrained to remain almost immovably, in the sitting posture, leaning the body slightly forwards, and resting his head on the back of a chair or some other sufficiently elevated support. The slightest variation from this pos- ture, unless very cautiously: effected, is apt, in some cases of this kind, to give rise to sudden and most poignant pains in the region of the heart. Extreme prsecordial anxiety, with a dry and short cough, usually attend ; and in many instances, partial syncope or sudden feel- ings of great faintness occur, at intervals during the progress of the disease. Along with these symptoms we have also strong evidence of cardial disturbance in the state of the pulse. In most instances the pulse is remarkably irregular, intermitting, frequently feeble, and sometimes so small as to be almost imperceptible. A few cases, indeed, have been recorded in which the pulse remained in nearly a natural state. Tacheron relates an instance of this kind.* The face is generally pale, with an occasional circumscribed flush on one cheek; the prolabia become more or less livid as the disease advances, and a slight puffy swelling is apt to occur about the eyes and temples. The hands and feet usually become slighly oedematous in the latter stage of the disease ; and great general weakness almost always ensues soon after the full development of the inflammation. The * Recherches Anatomico-pathologiques, &c. &c. 378 PERICARDITIS. speech is commonly faltering, and in some cases the patient is, unable to spit out, without giving rise to sudden and extremely severe dart- ing pains in the region of the inflamed organ. Sometimes considera- ble headache attends, and occasionally much uneasiness and pain are experienced in the stomach, accompanied with tenderness to pres- sure in the epigastrium. It must not be supposed, however, that pericardial inflammation is invariably attended with the train of symptoms just described. There are few phlegmasial affections so liable to such remarkable variations in the attending symptoms, as the disease under considera- tion. In some cases very little or no pain is experienced in the region of the heart; and the disturbance of the heart's action varies greatly in different cases, or at different stages of the same case. Most com- monly the heart palpitates tumultuously, and knocks violently against the ribs ; but. in some cases, its action is so feeble that its pulsations are scarcely to be felt or heard. Although the majority of patients are obliged to remain in a sitting or semi-recumbent posture, yet some are forced to lie immovably on their backs, or on the right or left side. " But the strangest anomaly is, that the same patient who, at one period of this disease, has fixed himself immovably on the left side, will, at another, be forced to turn over and fix himself as immovably on the right side." (Latham.) Pericarditis is not unfrequently complicated with inflammation of the neighbouring structures, as the pleura, lungs, mediastinum, dia- phragm, or stomach ; and in some cases, the substance of the heart itself participates in the pericardial inflammation. In instances of this kind, the symptoms are, of course, correspondingly complex. Diagnosis. — From the complications just mentioned, the diag- nosis of pericarditis is often attended with much difficulty ; and Laen- nec cautions, in all instances, against " too implicit a confidence" in the symptoms mentioned above as manifestations of pericardial in- flammation. Pericarditis, he says, may exist without any of these signs; and on the other hand, all of them may be present, without the slightest inflammation of the pericardium. M. Louis, however, asserts, that from a careful observation of thirty-two cases of this affection, he has been led to believe that the diagnosis is by no means so difficult and uncertain as is supposed by Laennec and others. This, he says, may be asserted, at least, of those cases that are free from complications. Where we find severe lancinating pains in the region of the heart, extending at intervals to the back and epigastrium, at- tended with palpitation of the heart; great irregularity, intermission, and smallness of the pulse ; difficult respiration; occasional syncope or great faintness; inability to rest in the recumbent position, with more or less oedema of the extremities, we may infer, without much risk of erring, the existence of pericardial inflammation. If with these symptoms we find the cardiac region yielding an obscure or dull sound, on percussion, while the other parts of the chest are reso- nant, the correctness of the diagnosis will hardly admit of a justifiable doubt. But, although we may, with but little risk of mistake, infer the existence of pericarditis when the foregoing symptoms are present, I \ PERICARDITIS. 379 it is well ascertained that rapid and violent pericardial inflammation sometimes occurs, and proceeds to a fatal termination, without at any period of its course manifesting a single symptom indicative of cardial disease. It is a very remarkable fact, also, that cases of this kind occasionally simulate inflammation of the brain so closely, that no one could for a moment hesitate to regard the disease as an instance of strongly-marked encephalic inflammation. Dr. Latham has recorded several highly interesting cases of this kind. "One of the children at Christ's Hospital, had, in the opinion of all who saw him, the severest inflammation of the brain. The attack was sudden, with great heat of the skin and frequency of the pulse. He had delirium and convul- sions, and pointed to his head as the seat of the pain." On dissection, not the slightest trace of inflammation within the head was disco- vered, but the heart and pericardium were intensely inflamed. M. Andral also relates a case where delirium, general convulsions, twitching of the tendons, and finally tetanic spasms, followed by para- lysis of the upper extremities and fatal coma, occurred without the least sign of any particular affection of the head. On dissection, the brain, spinal marrow, and their membranes, did not present the slightest traces of disease. But the pericardium exhibited strong marks of inflammation ; its surface was covered with a layer of concreted lymph, and several ounces of a green and flaky serum were effused into its cavity.* Causes.—In general, whatever is capable of causing inflammation of any of the thoracic organs or structures, may give rise to peri- carditis. Cold; mechanical injuries; the sudden healing up of old ulcers; the suppression of habitual evacuations; repelled cutaneous affections; the influence of the depressing mental emotions; and over- exertion of the mind, may produce the disease. Metastasis of rheu- matism and gout, is, however, by far the most common cause of this affection. Rheumatic irritation, especially, is frequently con- cerned in the production of cardiac affections. Under the head of hypertrophy, its tendency in this way will be particularly noticed. Pleuritis and pneumonia sometimes involve the pericardium. Autopsic phenomena.—In most instances a considerable quantity of serum is found in the pericardium. Louis mentions cases in which more than a pint and a half of reddish or yellowish serum was collected; and Corvisart saw an instance where it amounted to four pounds. The internal surface of the pericardium is generally much injected, and often rough and uneven, or covered with more or less extensive patches of false membrane. In some cases a simi- lar pseudo-membranous formation covers the surface of the heart. M. Louis mentions one where false membrane, nearly half an inch thick, in some places, covered the heart, so as to give it the appear- ance of the rind of a pine-apple. Laennec asserts that the quantity of serum effused into the pericardium, though considerable in the early stage of the disease, always decreases progressively, by absorp- * Pathological Essays on some of the Diseases of the Heart. By P. M. Latham, M. D., Physician to St. Bartholomew's Hospital. Lond. Med. Gazette, 1829. 380 PERICARDITIS. tion, as the violence of the inflammation declines. In cases of great violence, there is generally very little or no serum effused; but instead of this, a large portion of firmly concreted albumen usually covers the heart and internal surface of the pericardium, and in some instances, fills the whole cavity of this membrane, uniting it more or less firmly with the surface of the heart.* In cases that terminate favourably, this albuminoid concrete matter gradually becomes converted into cellular substance, " or rather into laminae of the same nature as the serous membranes." In some cases the pericardium is found very firmly adherent to the heart throughout its whole extent, by means of laminae of cellular structure thus formed. Cases are mentioned by some of the older writers, where the pericardium was supposed to be altogether wanting; but these were no doubt instances of firm adhesion of this membrane to the heart. Columbus relates the case of a student at Rome, who, after having for a long time suffered frequent attacks of syncope, died suddenly. On dissection, the heart, he says, was found unprotected, with a pericardium.! The pericardium has also been found affected with true scirrhous induration; and Dr. Friend asserts that he has found it above half an inch in thickness throughout its whole extent. J Chronic Pericarditis.—The chronic form of pericardial inflam- mation appears to be much more frequent than the acute. It is attended, in most instances, with more or less fixed pain in the region of the heart, subject to occasional exacerbations, particularly from even slight perturbating causes. Some degree of dyspnoea and pectoral oppression is seldom wholly absent; and a short dry cough is apt to occur. The pulse, as in the acute form of the com- plaint, is small, and at times irregular and intermitting; and the heart is apt to be thrown into violent paroxysms of palpitation by slight corporeal exertions and mental excitement. Patients labour- ing under this affection, are generally timid, pusillanimous, and dis- turbed by apprehension of evil, or of death. On percussion, the sound elicited over the region of the heart, is peculiarly dull; and when effusion has taken place, some degree of fluctuation may be felt by the patient. In most instances, oedema of the lower extre- mities occurs, and occasionally a puffy swelling appears suddenly in the face, particularly under the eyes, and after a day or two dis- appears again. When the sound on percussion over the cardial region is dull, and the extremities and face become puffy, we may conclude that considerable effusion of serum has taken place in the pericardium; and in this case the danger is always very great. Death from this affection often occurs very suddenly and unexpectedly; but in some instances a slow wasting of the body, and declension of the vital powers, under symptoms of general febrile irritation, gradually lead to a fatal termination. * Laennec. t De Re Anatomica, lib. xv, p. 267—as quoted by Van Swieten. X History of Physic, p. 2. PERICARDITIS. 381 On dissection, the whole internal surface is, usually, found florid; I but the pseudo-membranous exudation, so common and conspicuous i in acute pericarditis, is but rarely met with in this form of the dis- i ease. When albuminoid concretions of this kind do occur in chronic pericarditis, they are always " thin, soft, friable, and entirely resem- bling a layer of very thick pus." (Laennec.) The substance of the heart presents a whitish colour, " as if it had been macerated, several days, in water;" and it is sometimes of a much softer con- sistence than natural, whilst in other instances it possesses its normal degree of firmness. Laennec does not agree with those who sup- pose that the loss of colour in the muscular substance of the heart, is the consequence of inflammation ; but he does not advance any facts which can be deemed sufficient to repudiate this opinion. Treatment.—A direct and active antiphlogistic treatment is of course the only mode of management upon which any reasonable hopes of success can be placed. In cases attended with symptoms of pulmonic inflammation, the treatment should, in every respect, coincide with that which would be adopted in either pneumonia or pleuritis. Where the pericardial inflammation has supervened sud- denly, soon after the disappearance of external rheumatic inflamma- tion, blood-letting cannot, in general, be carried to the extent which is proper in cases arising from other causes. Indeed, the ordinary antiphlogistic means usually employed in phlegmasial affections, will rarely subdue rheumatic pericarditis; and copious abstractions of blood are not unfrequently productive of serious mischief. In cases of this kind calomel and opium, given in full and frequent doses, in conjunction with moderate general and local depletion and proper revulsive applications, constitute the most valuable curative means we possess. Dr. Latham speaks in the most favourable terms of the employment of mercury in pericarditis. It is particularly valuable in rheumatic pericarditis, although much advantage may often be obtained from its use in every variety of the disease. " From acute pericarditis," says Dr. Latham, " which has proceeded to the deposi- tion of lymph, nothing, I believe, can effect a perfect recovery, except mercury, given so as to excite moderate salivation." From my own observations, I am entirely convinced that calomel given to the extent of producing a general mercurial impression, is a valuable remedy in this affection. Where the disease is dependent on rheumatism, it will, I think, always be best to give the calomel in union with opium. In a case of rheumatic pericarditis, which came under my care about six months ago, I prescribed one grain of opium with three grains of calomel, every four hours, with unequivocal benefit. About sixteen ounces of blood were abstracted with the lancet, and thirty leeches applied to the region of the heart, before the calomel and opium were resorted to. Blistering on the back between the shoulders, whilst blood is abstracted by leeching or cupping from the anterior cardial region, is a very powerful auxiliary in reducing this affection. The saline hydragogue purgatives are probably better suited to procure advan- tage in this affection than the other articles of this class of remedies. 382 ACUTE RHEUMATISM. From what I have myself witnessed in relation to this point, I am led to believe that cremor tartar, with or without a portion of jalap, is the best purgative we can give in this affection. When the disease is of a chronic character, and there is reason to presume that serum has been effused in the pericardial cavity, diuretics will be proper. The squill, in union with calomel, may be employed for this purpose. In this form of the disease, a more permanent counter-irritation over the region of the heart, than can be well obtained by blisters, should be kept up. Pustulation with the tartar emetic ointment, or a caustic issue, will in general answer this purpose well. CHAPTER XV. OF THE PHLEGMASIA OF THE FIBROUS AND MUSCULAR STRUCTURES. Sect. I.—Acute Rheumatism. Acute rheumatism generally commences with the ordinary initial symptoms of febrile affections from cold or atmospheric vicissitudes. A sense of dullness, alternating with flushes of heat, with general lassitude, loss of appetite, and depression of spirits, are the usual symptoms which attend the development of the disease. In many instances, a general soreness and aching of the body accompany these symptoms. Sometimes the febrile reaction becomes completely estab- lished before the local rheumatic inflammation supervenes; in other instances, more or less pain is experienced in one or several joints, or in other fibrous structures, from the commencement of the attack; and occasionally, though rarely, the local affection occurs before any manifest general sympathetic irritation takes place. The parts af- fected with rheumatic inflammation are swollen, red, and extremely painful—the slightest pressure or motion causing the utmost degree of suffering. When perfectly at rest, the patient often experiences some abatement of the gnawing and tearing pain during the day; but at night intense exacerbations usually take place. Whether the fever precede or rise with the development of the local inflammation, it always acquires additional violence as soon as the local affection is fully established—the pulse becoming full, frequent,and vigorous; the skin hot and dry; the tongue coated with a white fur, changing to a brown colour, as the disease advances; the thirst very urgent; the bowels constipated, and the purine scanty, of a deep red colour, transparent, and without sediment. In very severe cases, headache, and, occasionally, slight delirium, attend during the exacerbations. Bilious Rheumatism.—Acute rheumatism is sometimes compli- cated with conspicuous derangement of the biliary organs. This is the rheumatismus acutus gastricus of Richter, and depends, accord- ing to StoU, on gastric irritation from redundant and vitiated bile in ACUTE RHEUMATISM. 383 the prima? viae.* Like bilious pleurisy, it is the result of the united operation of cold and koino-miasmata on the system. This variety of the disease is met with in miasmatic districts," during the cold and variable months of the year, more especially after a warm and sickly autumn. The disease is usually attended with considerable pain in the head ; a yellowish or icterode hue of the eyes ; a thick layer of brown fur on the tongue ; occasional nausea and bilious vomiting. The quantity of bile thrown up is sometimes very great; and after each spell of vomiting, an immediate and often almost complete, though but temporary, abatement of the local rheumatic pains usually occurs. Gonorrhceal Rheumatism.—Rheumatic pain and swelling of the knees and ankles, are no uncommon consequences of gonorrhceal irri- tation. In some instances, though rarely, the rheumatic affection becomes more general, very painful, and attended with very consi- derable febrile irritation. Cases of this kind have generally been ascribed to a suppression of the gonorrhceal discharge. This is the opinion of Brodie, and of Swediaur ; but Mr. Bacot thinks this ex- planation of its origin "is to be understood in a very qualified sense." It appears, however, to be pretty well ascertained, that " neither the affection of the joints nor the more general rheumatism, comes on until the gonorrhoea is on the decline." Young persons of " stru- mous habits, florid complexions, and not particularly robust," are most liable to this form of rheumatic affection. This form of the disease is characterized by much puffiness and tenderness of the ankles, especially towards evening ; the pain is not much increased by pressure—the stomach becomes deranged, and the appetite usually fafls altogether. Now and then, "all the symptoms are suddenly relieved by an eruption of papulae in clusters; or sometimes by pus- tules in minute patches." This eruption may continue from a few days to several weeks. When it appears, both the pains and consti- tutional symptoms go off entirely.! The rheumatismus non febrilis recens of the German writers, though diverse from the chronic form of the disease, is not attended with very obvious symptoms of febrile reaction. It shows itself by more or less severe and sharp pain in some one of the muscular or aponeurotic parts of the body, particularly in the muscles of the breast, neck, and about the scapular region," and occasionally in the face and jaws. Sometimes* the affected part is swollen and red; at others, neither swelling nor redness occurs. This variety of rheu- v mafic inflammation generally arises from the local application of cold, such as currents of air directed upon some particular part of the body4 Prognosis.—Although extremely painful, rheumatism is not a dangerous affection, so long as the inflammation remains in the ex- ternal parts. When translated to some internal organ or structure— * Ratio Meden., torn, ii, p. 25. t A Treatise on Syphilis, &c , by John Bacot, Esq., Surgeon. &c. X Richter, Specielle Therapie, vol. ii, p. 36. 384 ACUTE RHEUMATISM. particularly to the heart, meninges of the brain, stomach, or lungs, the most serious consequences are to be apprehended. The duration of an attack of acute rheumatism is extremely vari- ous, and depends much on the degree of constitutional predisposi- tion to the disease; and on the remedial management adopted for its removal. When the disease is about terminating, general diapho- resis, with a copious pale-red sediment in the urine, occurs; and, in some instances, moderate diarrhoea accompanies the declension of the fever and inflammation. It never terminates in resolution with- out the concomitant occurrence of diaphoresis and a lateritious sedi- ment in the urine. It would appear, from some observations of Dr. Chambers and Mr. Wigan, that the sweat in acute rheumatism is almost invariably of an acid quality.* I noticed this fact in a case I attended a few months ago. The patient wore a blue check shirt, the blue stripes of which were changed to a pale-red colour during the resolution of the disease. Rheumatism occurs but very rarely during early infancy. Scu- damore asserts that infants are entirely exempt from it; but. in this he is certainly wrong. I have met with several instances of acute articular inflammation, attended with the usual phenomena of rheu- matism, in children under two years old. Very aged persons, also, are seldom affected with the acute form of rheumatism, although especially liable to the chronic variety of the disease. From the seventh to the forty-fifth year of age, is the period during which acute rheumatism is most apt to occur. Lean and muscular persons of a sanguineous temperament are, in general, much more liable to this affection than individuals of a fat and soft habit of body, or of a nervous or lymphatic temperament. Among the most common and powerful accidental predisposing causes of rheumatism are, derange- ment and irritation of the alimentary canal; the inordinate use of spirituous liquors ; fatiguing exercise, accompanied with protracted and copious perspiration; and the habitual use of high-seasoned and heating articles of food; and the abuse of mercury. Causes. — Suppressed perspiration from cold or sudden atmosphe- ric vicissitudes is incomparably the most frequent exciting cause of rheumatism. It is on this account that the disease is so much more common during the damp, raw, and variable months of spring and autumn, than in the more mild and equable season of summer. In- deed, rheumatism is almost peculiarly a disease of cold and variable climates—its occurrence in the warm and more uniform latitudes being comparatively rare. Mercury is generally accused as a very frequent cause of rheumatism. It is doubtful, however, if it is ever, of itself the exciting cause of this affection, although its very espe- cial tendency to predispose the system to the morbific influence of low and variable temperature is unquestionable ; and it is, probably, by this effect alone, that the use of mercury is so apt to be followed by rheumatic affections. I have already adverted to gonorrhosal irritation as an occasional cause of rheumatic affections. It would * Medico-Chirurg.Rev., April, 1828, p. 176. ACUTE RHEUMATISM. 385 appear that the occurrence of the arthritic pains is in some way or other connected with the disappearance of the gonorrhceal discharge, but whether the cessation of the discharge is to be regarded as the effect or the cause of the rheumatic affection, is, as yet, a matter of conjecture. In relation to the proximate cause of rheumatism, authors have expressed a variety of opinions. Formerly it was customary to re- gard the disease as depending directly on a peculiar morbific or rheumatic matter in the blood, which being thrown or concentrated upon some particular part, was thought to be the immediate exciting cause of local inflammation. Balfour advanced the opinion of its consisting in a peculiar inflammation of the cellular tissue; and Cullen supposed that an inflammatory state of the blood, in connec- tion with a peculiar phlogistic condition of the muscular structure, constitutes the proximate cause of the disease. With Broussais, it, of course, is the consequence of the all-embracing gastroente- ric The opinion of Richter, that rheumatic inflammation is the consequence of irritation from retained perspirable matter (materia perspirabilis relenta*), though savouring too much of humoral pathology for the prevailing taste of pathologists, is at least as plausi- ble as any other doctrine that has been advanced on this subject, and by no means at variance with the immediate effects of its acknow- ledged almost invariable exciting cause. Whatever ideas may be entertained in relation to the proximate' cause of rheumatic inflammation, it is now generally admitted that the seat of this inflammation is in the fibrous texture—more espe- cially in the aponeurotic and tendinous structures of the body. It is manifest, moreover, that this inflammation differs very materially from the other varieties of inflammation; and the opinion of Scuda- more, that it is, sui generis, of a strictly specific character, is sup- ported by its peculiar character and phenomena. The frequent, and often rapid passage of the local affection from one part of the body to another, would seem to indicate something radically distinct, if not in the inflammatory action itself, at least in its immediate or proximate cause. This circumstance, too, favours the opinion that the disease consists in a peculiar diathesis, or general morbid condi- tion of the system—the local inflammation being merely one of its effects, or external manifestations. We notice this migratory character in all inflammations which depend on some internal or constitutional affection. It occurs most conspicuously in gout, and in some varieties of erysipelas. Metastasis of rheumatic inflammation to internal organs or struc- tures, and consequent alarming and sometimes fatal consequences, is by no means unfrequent. It may pass upon the' heart, diaphragm, stomach, bowels, intercostal muscles, and, in short, upon almost every sensible part of the body. When it is translated to the heart, the patient is seized with acute pain and a feeling of great anxiety in the cardiac region, with palpitation, fits of partial syncope, and a pale, * Specielle Therapie, vol. ii, p. 18. vol. I.—25 386 ACUTE RHEUMATISM. contracted, and distressed aspect of the countenance. Metastasis to the meninges of the brain, is attended with a sense of weight, and sometimes acute pain in the head, intolerance of light and sound, a wild and anxious expression of the countenance, occasional delirium, strabismus and impaired vision.* When the stomach becomes the seat of the disease, violent cardialgia, nausea, vomiting, indigestion, "and symptoms imitating cancer or scirrhus of the pylorus," usually supervene. Cazenave says, that in some cases, nothing but a feeling of coldness or pain occurs in the epigastric region.t The same writer states, that he has known the bladder to be affected with rheumatism —producing retention of urine, and much pain in the vesicle region. Sometimes the lungs become the seat of the disease, in which case symptoms of peripneumony supervene. When it attacks the inter- costal muscles, or the pleura, the phenomena of pleuritis occur. Ca- zenave states, that he has repeatedly known rheumatic inflammation to fix upon the uterus and its appendices, giving rise to severe pain in this organ. I have lately seen an instance of sudden translation of rheumatic inflammation from the wrist to the bowels, in a young lady, which was speedily followed by symptoms of subacute peri- tonitis.. On the fourth day the pain and swelling reappeared in the arm, and the abdominal affection speedily subsided. Dr. Johnson observes, in relation to this disease, that though not often fatal as ex- ternal rheumatism, yet in its consequences, he is led, from "long and attentive observation," to regard it as being productive of "a very considerable proportion of those active enlargements or hyper- trophiae of the heart, which we now so frequently meet in practice." Dr. Cox also refers to the "numerous cases of organic disease of the heart and pericardium, which he met with during his connection with St. George's Hospital, that were referable to, or connected with rheu- matitis."J His observations have led him to believe that the "majority of cases of organic disease of the heart in young people, are connected with rheumatism." Diagnosis.—By the ancients, rheumatism and gout were generally described under the common name of arthritis, and it does not ap- pear that they regarded these affections as being diverse from each other. The essential identity of these two diseases has, indeed,.found advocates among modern pathologists, although the general sentiment, at present, is that they are radically distinct from each other. The principal distinguishing circumstances between these two affections are:—1. The periodical recurrence of gout after it has once invaded the system; whereas, rheumatism does not possess this tendency, the patient often remaining entirely free from the disease during the rest of life, after having suffered an attack of it. 2. The distinct character of their causes; thus, rheumatism is conspicuously and almost in- variably, the result of atmospheric inclemency or vicissitudes causing * Observations on Acute Rheumatism and its Metastasis to the Heart. By Thos. Cox, M. D., London, 1824. t Memoir on the Treatment of Rheumatism. By Dr. Cazenave. X Loc. citat., preface, viii. ACUTE RHEUMATISM. 387 sudden depression of the cutaneous exhalation.* It is not produced like gout, by indolence, in conjunction with the free use of vinous drinks, and rich, high-seasoned, and stimulating articles of diet. An attack of acute rheumatism is not usually preceded by uneasy sensa- tions in the stomach, and other gastric disturbances. Gout is very often preceded by dyspeptic symptoms. 3. The predisposition to gout is often transmitted from parent to offspring. This is rarely if ever the case, in relation to acute rheumatism. 4. Gout is most apt to occur in debilitated and relaxed habits; its occurrence in lean, muscular, and temperate persons inured to hardships and toil, being extremely uncommon; whilst the reverse, in all these respects, obtains in rheumatism. Treatment.—Although of a strongly marked phlogistic character, rheumatism is not so much under the control of direct depletion as most of the other phlegmasial affections. Blood-letting is undoubtedly a very important auxiliary in the treatment of this disease ; but it is incapable, by itself, of subduing the local inflammation, however copiously practised. Indeed, the very profuse, sanguineous evacua- tions so frequently resorted to in this complaint, so far from proving beneficial, lead often to very disastrous consequences; for experience has fully established the fact, that metastasis of the local affection to an internal organ is particularly favoured by thus draining the system of its blood, and impairing the vital energies. " We have long been convinced," says Dr. Johnson, " from attentive observation, that the system of detracting large quantities of blood in cases of acute rheu- matism, is productive of more frequent metastasis from the extremi- ties to internal organs than a more moderate treatment. If we do quell the external inflammation, a retrocession to some weakened organ is too apt to take place. Of this we have seen several in- stances."t The records of medicine furnish us with many examples illustrative of the correctness of this observation. The case reported by Dr. Kempher is a striking instance of this kind. This was a strongly-marked case of inflammatory rheumatism; the fever was violent and "the joints of her limbs, from the elbows and knees down- wards, were affected with swelling, redness, and most acute pain." In five days, nearly eleven pints of blood were abstracted from the patient. Metastasis of the disease soon took place, first to the lungs, and then to the head. At last the rheumatic inflammation returned to the extremities and relieved the internal organs.J Dr. Armstrong also has related a case of this kind.§ The inordinate use of the lancet, by debilitating the constitution, is, moreover, apt to prolong the dis- * Richter says, rheumatism is always produced by external exciting causes, such as cold, and, therefore, more immediately from a materia perspirabilis retenta. Whereas gout arises, from internal causes, giving, rise to a peculiar atony and weakness of the system. t Medico-Chirurg. Review, June, 1823, p. 215. X Philadelphia Journ. Med. and Phys. Sciences, No. 12. § Lond. Med. and Phys. Journ., No. 289. 388 ACUTE RHEUMATISM. ease in a subacute or chronic state, and to strengthen the predisposi- tion to a recurrence of the affection. " In no way," says Scudamore, " is a degeneracy into chronic symptoms so certainly induced, as by that injudicious employment of general bleeding which enfeebles the constitution, and still leaves the rheumatic disposition in great force. Nor does the articular disease itself yield to the use of general bleeding in the manner which we might expect."* Blood-letting is, however, not to be entirely neglected in this affec- tion. It is only against the too common abuse of this evacuation. that these observations are directed. In strong, muscular, and ple- thoric subjects, general bleeding, until some impression is made on the pulse, is a useful preliminary to the employment of the more effi- cient remedies in this affection. In general, one or two pretty copious evacuations in the commencement of the disease, will be sufficient to procure all the advantages this measure can afford. The attempt to render the pulse soft and moderate in its action by blood-letting in this disease, will almost always fail, unless blood be drawn to a very dan- gerous extent. The usual indication furnished by the buffy coat of the blood, for further depletion in inflammatory affections, is wholly fallacious in rheumatism; for the buffy coat will generally continue in despite of the most copious and repeated abstractions of blood. "A surer practical indication may be taken from the form of the coagulum and its firmness. When it is exceedingly cupped, and when the inferior part beneath the stratum of fibrine is very firm, it is a presumptive evidence that the heart and arteries are labouring under that morbid contractility which distinguishes the inflammatory dia- thesis."! When the disease fixes itself early on some internal organ—par- ticularly the heart, diaphragm, or brain, it will be necessary to resort to prompt and decisive bleeding; but even in cases of this kind, it will be much better, after one or two copious abstractions of blood, to resort to the use of opium and calomel, than to a repetition of the bleeding. Purgatives are always useful in this affection. I have often known the inflammatory condition of the system more effectually reduced by the operation of two or three saline purgatives, than could be effected by several copious abstractions of blood. The more drastic articles of this kind ought to be avoided. These are in some degree incompatible with that regular action of the cutaneous exhalents which seems to be indispensable to the removal of this affection. Laxatives, on the contrary, are of much service by removing the sources of intestinal irritation—equalizing the circulation, and mode- rating the febrile reaction, without causing injurious irritation by their direct impressions on the mucous membrane of the bowels. As a general rule, the saline purgatives are to be preferred. I have usually directed from six toeight grains of calomel at night, to be followed next morning by a small dose of Epsom or Glauber salts. Scuda- * A Treatise on the Nature and Cure of Rheumatism. London, 1827, p. 70. t Scudamore, loc. citat., p. 70. ACUTE RHEUMATISM. 389 more speaks very favourably of an aperient draught composed of small doses of carbonate of magnesia, carbonate of potash, sulphate of magnesia, with tartarized antimony, acetum colchici, and lemon juice sufficient to neutralize the carbonate of potash, and a portion of water and syrup. Two ounces of Epsom salts, with a grain of tartar emetic, dissolved in eight ounces of water, and taken in doses of a tablespoonful every hour, are an excellent aperient in this complaint. Emetics have been much recommended in the treatment of rheu- matism, and my own experience has furnished me with some striking examples of their usefulness. Horn asserts that he has derived more prompt advantage from emetics in this complaint, than from any other remedy.* I attended a gentleman, a few years ago, who was suffer- ing extremely from an attack of acute rheumatism. The principal pain and swelling were in all the joints of the left arm, and in the right knee. He had been freely bled and purged before I saw him, but the pains continued unabated. With a view to excite diaphoresis, and to moderate the febriie reaction, I prescribed a solution of tart. antim. Contrary to my intentions, the first dose produced pretty free vomiting. Almost immediately his pains were greatly mitigated, and continued so for three or four hours, and then gradually returned, though not to their former state of violence. On the following morn- ing, I gave him an antimonial emetic which produced full emesis, and again the rheumatic pains subsided, almost entirely for a few hours ; they returned, however, as before, but so greatly diminished, that he was enabled to obtain considerable sleep during the following after- noon and night. On the third day, he took another emetic, after which the disease disappeared rapidly and completely, under the use of a few full doses of opium. I have, since that time, derived signal advantage from emetics in several cases of this affection. When rheumatism is complicated with functional disorder of the liver, emetics are particularly useful. In instances of this kind, the local pain will often almost entirely disappear for a time; and if full doses of calomel and opium are administered soon after the vomiting has ceased, convalescence will sometimes speedily ensue. Diaphoretics may be employed with advantage, although little or no benefit is usually derived from profuse sweating excited by reme- dies of this kind. A gentle and uniform diaphoresis is always ser- viceable. For this purpose, small doses of tart, antim. in union with calomel and opium ;t or with camphor and nitrate of potash \% * Uber d. heils: wirk. d. brechmittel in hitzigen rheumat. Archiv., b. viii. s. 2. t R.—Tart, antim on. gr. i. Pulv. gum. opii gr. iii. Calomel gr. iv. Pulv. sacch. albi gr. xii.—M. Divide into eight equal parts. S. Take one every two hours. X R.—Tart, antimon. gr. i. P. g. camph. gr. viii. Calomel gr. iv.—M. Divide into eight equal parts. S. Take one every two or three hours. 390 ACUTE RHEUMATISM. or Dover's powder with calomel, may be advantageously employed. Scudamore recommends the following diaphoretic and anodyne mix- ture as particularly beneficial in this respect: R.—Potassa; carbonat. gr. cviii. Succi citric, (recentis) §ii. Misturae camph. ^iiiss.. Liquoris opii sedativ. giss. ad 3d. Syrupi tolutan. gss. Antim. tartarisat. gr. i. ad gr. ii.—M. Of this mixture, one, two, or three tablespoonfuls are to be taken every hour or two, until the pain is relieved. The diaphoretic tendency of these remedies should be promoted by the use of warm diluents ; such as weak infusion of eupatorium perfoliatum, of elder blossoms, &c. Opium, under judicious management, is a valuable remedy in acute rheumatism. When employed in full doses, after proper venesection and purging, in combination with calomel, or with ipecacuanha, or tart, antim.,* it seldom fails to procure speedy relief, and to hasten the resolution of the local and general inflammatory action. When, after copious depletion, or from constitutional feebleness, the rheumatic inflammation passes upon some internal organ, opium is almost the only remedy upon which any reasonable hope of advantage can be placed. In my own practice, I have had many striking examples of the usefulness of this narcotic in the present affection. It should be given in full doses, and repeated every three or four hours, until relief from the pains is procured. Small doses of opium have a tendency to increase the phlogistic diathesis, whilst large ones, properly re- peated, generally produce a contrary effect in acute symptomatic fevers. " It is worthy of consideration," says Scudamore, " that so powerfully does pain modify the influence of opium on the nervous system in every kind of disease, that it may be given in the boldest doses without hazard or ill effect, when pain is intense; and in no ivay except by the active repetition of such doses can it be really efficacious when the occasions for it are urgent." Dr. Cazenave very justly observes, that the timidity with which this narcotic is usually administered in acute rheumatism, is the cause of its frequent failure in doing conspicuous good. His mode of using the opium, * Tartarized antimony and opium have been employed with signal efficacy in rheumatism. Dr. Findlay, of Circleville, Ohio, has published an account of seve- ral severe cases of this disease which yielded very promptly to a combination of these remedies. He gave about one grain of the antimony with two-thirds of a grain of opium every hour, (a) I have myself lately employed this remedy in several cases, and with very speedy and entire success. Not more than four doses were required in an extremely severe casejbf lumbago^to put an entire stop to the pain. M. Lallemand speaks very favourably of grain doses of tart. antimony in rheumatic affection's; and it is, in fact, a remedy of excellent powers in this respect. (a) North American Med. and Surg. Journ., vol. x, p. 167. ACUTE RHEUMATISM. 391 in this affection, is to give a grain of it every hour, « till a complete calm is established, or an abundant perspiration induced." Most practitioners who are in the habit of employing opium in rheumatism, use it in combination with calomel; and this has ap- peared to me the best mode of using it. After venesection, and the free operation of a cathartic, I generally resort at once to opium and calomel, in the proportion of one grain of the former to two of the latter every three or four hours, until the gums are slightly affected; after which I continue with half a grain of the opium, at first every three hours, and gradually prolonging the intervals in proportion as the disease subsides. I have frequently found, that as soon as the mercurial action was established, the skin became moist and relaxed, the pulse soft and less frequent, the urine sedimentous, with a rapid declension of the local and general affections. Dr. Armstrong ob- serves, that after prompt venesection followed up by purgatives with calomel and opium, recovery is often surprisingly rapid. Many highly respectable authorities might be cited in favour of the united employment of these two articles in rheumatism.* "This treatment of acute, and we may say chronic rheumatism," observes Dr. John- son, "is employed by many practitioners, and it is that which we have had recourse to for twenty years past."t It is not necessary to continue the calomel to the extent of producing free ptyalism. The slightest evidence of the mercurial action in the gums, is in general sufficient. The cinchona was formerly much recommended in the treatment of this affection. When, after depletion and purging, distinct remis- sions of the febrile symptoms occur, particularly in weak and relaxed habits, the powdered bark or quinine may be employed with advan- tage. But in robust, muscular, and sanguineous habits, it is much more apt to do harm, under any mode of management, than benefit. I have known very manifest injury done by the bark in this affec- tion. During convalescence it is a proper and useful remedy. Colchicum was at first prescribed only in the subacute or chronic forms of rheumatism: but later experience has shown that it may be employed with equal benefit in the acute form of the disease. Mr. Hayden, in his work on the remedial powers of this root, asserts, that it possesses very considerable powers in controlling the action * Dr. Chambers, of St. George's Hospital, London, gives ten grains of calomel, with two of opium, every night, or night and morning, with a daily dose of black draught to evacuate the bowels. He states, that as soon as the mouth becomes affected, the symptoms usually subside. He does not push the medicine to the extent of producing ptyalism.—Med. Chir. Rev., vol. v. p. 566. Mr. Gosse, of Geneva, has employed calomel and opium to ptyalism with success, in acute rheumatism. From some chemical experiments which he made with the blood of persons under salivation, he found that it contained much less albumen, as well as cruor, and was more liquid than usual; and that it is there- fore less inflammatory. Similar opinions have been expressed by Dr. Farr and Mr. Travers.—Med. Chir. Rev., vol. i. p. 482. f Med. Chir. Rev., October, 1826, p. 566. 392 ACUTE RHEUMATISM. of the heart, and subduing inflammatory excitement. I have exhi- bited this article in seven or eight cases of acute rheumatism. In one instance it removed the disease completely in the course of three days, although previously very violent, and after calomel and opium, tart, antimon., venesection, and free purgation had been ineffectually used. In a few instances it appeared to do some good, but in others no advantage whatever resulted from its use. Recently, however, I prescribed it in two instances of a subacute character with the happiest effect. Both patients were relieved by it in forty-eight hours, although the disease had for several weeks resisted other modes of treatment. Scudamore recommends the following formula for administering this remedy, where the inflammatory diathesis is not strong: R-.—Liquor, amnion, acetat. ^ss. Vini colchici gtt. xx. ad xxx. Syrupi papaveris gi. Misturse camph. §i.—M. This draught is to be taken every sixth or eighth hour. The vinous tincture of the colchicum seed may be given to the extent of from twenty to thirty drops, with about a scruple of cal- cined magnesia every four hours, until slight nausea or purging is produced. When acute rheumatism continues until it assumes a subacute character—the pulse remaining irritated, small, sharp, and frequent, and the countenance pale, while the affected joints are swollen, painful and oedematous—great benefit may sometimes be derived from the extract of stramonium, given in quarter grain doses every four hours until vertigo ensues. I have succeeded in removing the disease, in a short time, in several instances of this kind, by means of the stramonium, after various other modes of treatment had been employed without avail. Very little advantage is in general to be obtained from local treat- ment during the active period of the disease. After the general in- flammatory excitement has in a great degree subsided, benefit may be derived from leeching the affected parts. I have also known much good done by blistering the inflamed joints under such circum- stances. The treatment by compression, so strongly recommended by Bal- four, has not met with much approbation; less I think than it deserves. I have, in a few cases of subacute rheumatic inflammation, known very considerable relief obtained from a flannel roller applied pretty firmly round the affected joint.* The diet should, of course, consist of the mildest liquid farinaceous articles of food. The drink may be cool and acidulated except when diaphoretics are administered, when tepid diluents should be used. The temperature of the sick chamber should be kept comfortable and uniform. * Observation on the Pathology and Cure of Rheumatism. By William Balfour, M.D.—Edinburgh Med. and Surg. Journal, April, 1825. CHRONIC RHEUMATISM. 393 Sect. II.—Chronic Rheumatism. The symptoms of chronic rheumatism are much less uniform and definite than those which characterize the acute form of the disease. Chronic is often the consequence of acute rheumatism ; but it occurs also, frequently, as a direct consequence of exposure to cold and damp air, more especially when the system is under the influence of mercury. The affected parts are commonly neither swollen nor red; nor is there often any manifest fever connected with the chronic variety of the disease ; although quickness, tension, and contraction of the pulse are in some instances present in the evening, and dur- ing the night. The pain often wanders from one part to another, fixing itself by turns in the head, shoulders, knees, wrists, fingers, hips, loins, &c.—more especially in those cases which approach the subacute character. Some individuals are hardly ever entirely free from pain; others are affected with it only occasionally, on the oc- currence of damp and cold weather. In some instances, the pain is seated in the joints; in others, in the muscles and parts situated between the joints. After remaining at rest for a while, the patient feels stiffness and pain on attempting to move the affected limb ; but on using exercise, until the body becomes warm, both the pain and stiffness are apt to disappear. Those who are subject to this form of the disease, generally feel a dull aching pain in one or more joints, on the approach of stormy or rainy weather. Severe and invete- rate cases of chronic rheumatism are apt to give rise to organic dis- ease of the tendons, bursae mucosas, with wasting and hardening of the muscular structure about the affected parts. The ligaments, also, sometimes become rigid, thickened, and the joints stiff. A jelly-like effusion into the cavity of the affected joints occurs occasionally. (Scudamore.) When the disease affects the muscles of the loins, it is called lum- bago. Lumbago is distinguished from nephritis by the absence of pain along the ureters, or retraction of the testicles, of the frequent desire to void urine, and of the nausea and vomiting which charac- terize the real disease. In lumbago, too, great difficulty and pain are experienced in bending the body forwards on the hips. In nephritis no uneasiness is caused by this movement. When the periosteum of the anterior aspect of the tibiae, or of the ulna, or os frontis, be- comes thickened and tender to the touch, we may presume that the chronic rheumatic affection is syphilitic or mercurial. Chronic rheumatism sometimes occurs as the sequel of the acute form of the disease; and it arises frequently, also, as a direct conse- quence of suppressed perspiration from cold, damp, and variable weather. It is generally supposed that the action of mercury is particularly apt to give rise to chronic rheumatic pains; but it is extremely doubtful whether it possesses any direct tendency in this way. That the system, when under the mercurial influence, is ex- tremely susceptible of the injurious effects of cold and humid air, is, indeed, sufficiently ascertained; and it is probable that when rheu- 394 CHRONIC RHEUMATISM. matism follows the constitutional operation of mercury, it is always the immediate consequence of subsequent influence of cold. Syphilis is apt to give rise to distressing chronic pains of a rheumatic charac- ter, but even where syphilis appears to be its cause, it is probably often the consequence of improper exposure while the system is under the mercurial influence. Mr. Teal has recently published a small work on subinflammation and irritation of the spinal marrow, in which he asserts that not only neuralgic but rheumatic affections frequently depend on irritation, or a slight degree of inflammation, at the origin of the spinal nerves. His observations on this subject appear to me highly important, and from an instance which has quite lately come under my notice, I am satisfied that in some cases at least, chronic pains of a rheumatic cha- racter depend on spinal irritation. Dr. J. K. Mitchell, of this city, has, within a short time, published an interesting paper on this subject, in which he has detailed several striking instances of the speedy re- moval of severe pains of this kind, by cupping over the spinal region. It would appear from the observations of Teal and Mitchell, that in many cases of fixed pains, simulating rheumatism, one or more of the vertebrae of the spine are very tender to pressure, and that, if in such cases leeches or cups be applied over the diseased portion of the spinal marrow, almost immediate removal of the rheumatic pains will be affected. In the case which occurred in my own practice, the patient had complained of constant severe pain in the left foot for several months, and the usual means for the cure of such affection procured only slight temporary benefit. Instructed by the cases reported by Dr. Mitchell, I at last examined the track of the spine, and found two of the lower lumber vertebrae morbidly sensible to pressure. I directed thirty leeches to the part, which afforded great relief, and in a few days afterwards more blood was drawn from the same spot by cupping, and this had the effect of entirely removing the disease in the foot. When the pains are situated in the head and upper extremities, the spinal affection, if any exist, will be found in the cervical vertebrae; and when a part about the chest, and upper portion of the abdomen, is the seat of the painful affection, there will probably be spinal irritation in one or more of the dorsal vertebras. Under the head of neuralgia, I shall again have occasion to speak of this subject; and, in fact, the painful affections which result from this cause, are probably always strictly of a neuralgic character, although often mistaken for chronic rheumatic inflamma- tion. I must again repeat, that the facts developed by Mr. Teale, are highly interesting, and will, no doubt, receive due attention from the profession. Treatment.—Unless the patient be robust, vigorous and pletho- ric, general blood-letting is not only useless, but often injurious, in the strictly chronic form of the disease. Attention should be paid to the state of the digestive functions, and to the bowels. Where the appe- tite is weak and variable, and the bowels inactive, five or six grains of blue mass should occasionally be taken at night, followed in the morning with some gentle aperient—such as the aromatic tincture of CHRONIC RHEUMATISM. 395 rhubarb; or a small dose of the compound infusion of senna. Where there is a general sluggishness or languor of the system, the cinchona bark, or quinine, will sometimes prove decidedly beneficial. Certain diaphoretics of the stimulating kind have been much employed in the treatment of this variety of rheumatism; and of these gum guaia- cum has held by far the highest rank. In individuals of a relaxed and phlegmatic habit of body, and in old persons of a worn-out con- stitution, it may be used occasionally with much advantage; but in persons of a contrary habit—plethoric, athletic, and phlogistic—it will seldom do good, and is even apt to do harm by its heating and irritating qualities. The usual mode of giving it in the form of a tincture, renders it still more objectionable in habits of this kind. In all instances, perhaps, it is best to give it in the form of an aqueous mixture, thus: R.—Pulv. g. guaiaci. §i. ----g, Arabic giii.—Triturate them together in a mortar, and add gra- dually ten ounces of cinnamon water. Of this, three or four tablespoonfuls may be taken daily. In cases partaking of a subacute character, or in such as result from the influence of cold while the system is under the operation of mer- cury, tart, antimon. will occasionally prove beneficial. In instances of this kind, I have used this article dissolved in a decoction of the root of burdock, (arctium lappa,) with excellent effects. A grain of the tart, antim. should be dissolved in a pint of the decoction (an ounce of therootto a pintof water),and drank in the course of the day. In such cases, however, more advantage may in general be derived from the judicious employment of mercury. In syphilitic and mer- curial rheumatism, the production of a gentle mercurial impression on the system, with the concomitant employment of the compound decoction of sarsaparilla, will often effectually eradicate the disease. But even in cases which are not connected either with a syphilitic taint or with mercurial disease, this remedy will sometimes prove decidedly beneficial. In inveterate and obstinate cases of chronic rheumatism, says Scudamore, "a well-conducted mercurial course, so as to produce and keep up a very moderate ptyalism, will sometimes prove successful after the failure of all other means." Advantage may be obtained from the use of the vapour-bath as an auxiliary to the mercurial course. I have used the following decoction, conjointly with mercury, with peculiar advantage : R.—Rad. sarsaparil. §iii. Fol. cymapylla umbelat. giss. Rad. mezereon ^iii. Cort. ulmi fulv. giss. Aqu. fervent. Ibiii.—To be boiled down to three half pints; of which a wine- glassful is to be taken four times daily. In the same variety of chronic rheumatic pains, I have also admi- nistered the sulphate of zinc, in one grain doses three times daily, with the happiest effects. In one instance, after mercury, sarsaparilla, and 396 CHRONIC RHEUMATISM. a variety of other remedies had been fully tried without success, the zinc gave complete relief. The extract of stramonium is highly recommended as a remedy in this affection by Dr. Marcet; and it is unquestionably an article of very valuable powers, in chronic painful affections, unconnected with a phlogistic state of the system. Twenty years ago I employed the tincture of the stramonium seed in chronic rheumatism ; and I have frequently found it promptly and completely successful, although often also entirely disappointed in its use. In some parts of the United States it has long been used as a domestic remedy in this affection; and it was from having seen it successfully employed by an old fe- male in a case which had foiled all my efforts, that I first learned its remedial powers in this disease. I usually give 20 drops of the saturated tincture of the seed three times daily; and direct it to be continued until vertigo, or symptoms of gastric disturbance ensue. I have also employed the extract of stramonium in union with lactuca- rium, as is recommended by Scudamore, with excellent effect. " In some recent attacks," says this writer, "in which wandering nervous pains have been mixed with lumbago, the effects of this combination have been surprisingly successful. In a few cases, even of long stand- ing, I have derived much satisfaction from this remedy." Colchicum is a remedy of considerable powers in chronic rheu- matic affections. I have found it most useful, however, in subacute cases, and in such as are the consequence of the acute form of the disease. In instances of a strictly chronic character, I have never derived any obvious advantage from this article; in such cases, it is, I think, inferior in efficacy to the stramonium.* In mercurial and syphilitic pains, arsenic will often manifest very excellent powers. It may even be given with occasional advantage in old and obstinate cases arising from other causes—and it is said to be particularly beneficial in such as depend on the repulsion of some chronic cutaneous affection. In several instances of a mercurial origin, I have prescribed Fowler's solution with complete success. After what has already been said above, I need scarcely dwell on the propriety of examining the spinal column, in chronic pains of a rheumatic character. When any portion of it is found unusually tender to pressure, leeches, cups, or a blister, should immediately be applied over the tender part. If the disease be the consequence of spinal irritation, it will frequently speedily disappear under the use of these local remedies. A great variety of other internal remedies have been recom- mended for the cure of this form of rheumatism. Of these, savin, nux vomica, phytolacca, decandra, dulcamara, hyoscyamus, sul- * [Laterigues pills, the composition of an eminent apothecary of Bordeaux have become quite a popular remedy here in chronic rheumatism and gout. They are composed of: J&.—Ext. colocynth. comb. gr. iss. Ext. colchici gr. iss. Ext. digitalis gr. iss.—M. One of these is given every sixth hour.—Mc] CHRONIC RHEUMATISM. 397 phur, turpentine, and xanthoxylum fraxineum are the most im- portant. The savan is an old remedy in chronic articular pains ;* I knew an empiric about twenty years ago, who was noted for his success in curing chronic rheumatism. His remedy was an electuary composed of savin, sulphur, and honey. I have prescribed it in a few instances with benefit; but in several cases its effects were mani- / festly injurious. vS.f", <- In chronic rheumatic pains of the hips (sciatica) and muscles of ;/.<,-*-> ' the loins (lumbago) the spirits of turpentine is among our most-^ ; efficacious remedies. Home states, that he cured five out of seven'^ ' cases of sciatica with this article.! Within the present year I suc-.Jy^"*" ceeded completely in removing a violent and protracted case of this /^wj affection by the turpentine, given Jn doses of twenty drops with a ' srcuple ofjac sufphuris three times daily. Oia'v^'kmTwtiflie infu-' 7 & j>'*' sion of capsicum employed with marked Advantage in a case of inveterate chronic rheumatism; and the juice of the poke-berries, (Phytolacca) is a familiar remedy in this affection, and has occasion- ally done considerable good. While practising in Lancaster county, I saw several instances of the successful use of a decoction of xan- thoxylum in chronic rheumatism. Professor Wendt has found an infusion of the clematis recta and vitaba a very useful remedy in this disease. Various external applications have been resorted to with advan- tage in this affection. The application of the tourniquet, so as to cause a temporary interruption in the circulation of the affected part is said to have done much good.J Lately, the vapour of camphor has been used with success in chronic rheumatism by M. Delormel and M. Dupasquier.§ The whole surface of the body, with the ex- ception of the head, is to be exposed to the fumes of camphor, in an apparatus similar to the one used for the sulphurous vapour-bath. The camphor is evaporated by throwing it upon a dish of hot coals. Acupuncturation has, of late years, been practised by many phy- sicians in local rheumatic pains unconnected with fever; and the numerous accounts that have been published respecting its effects, are sufficiently favourable to entitle it to considerable attention. Mr. Berlioz observes, that " vague and wandering rheumatism sometimes attacks the external muscles subservient to respiration : the patient is obliged to remain motionless; every motion of the trunk compels him to cry out; deep inspiration is very difficult; and cough occasions such intense pains that expectoration is impossible. Acupunctura- tion dissipates instantly this state of distress, and renders the muscles their full liberty of action. In the space of one or two minutes, a patient whose sufferings drew from him tears, becomes entirely relieved." This operation has been found particularly efficacious in * Rave, Beobachtungen, &c—Munster, 1796. t Clinical Observations and Experiments. X Richter's Specielle Therapie, b. ii, s. 61.—Abhandl. fur Pract. Arzte, b. xx, p. 509.—See also Duncan's Annals for 1801. $ Rev. Medicale, Mai, 1829, p. 298. 398 GOUT. lumbago; and instances of its successful employment in sciatica have been reported. Acupuncturation should, however, never be practised in cases attended with general febrile irritation; or in in- flammations approaching the acute character. Electro-puncturation—that is, inserting two needles, and connect- ing them with the opposite poles of a weak galvanic pile—has suc- ceeded in cases after ordinary acupuncturation, repeatedly performed, had entirely failed. Dr. Graffe has reported a very severe case of rheumatism, of several years standing, which, after having resisted every remedy and mode of treatment that could be suggested, yielded, at last, to the influence of electro-puncturation.—(Graffe and Wal- therms Journal.) Rubefacients are always useful in cases of a strictly local cha- racter. Camphor dissolved in asther, as recommended by Ferriar, is an excellent application for this purpose. I have generally preferred using the following liniment: R-.—Spir. camphor. Aquse ammon. aa §iss. 01. olivar. %i. Spir. vini rect. ^iv.—M. The warm bath, in conjunction with mercurial or diaphoretic re- medies, has been useful in this affection. Baths and douches of artificial sulphurous waters have been particularly recommended. In local rheumatic affections, advantage may sometimes be obtained from blistering or cupping the affected part; but the benefits derived from means of this kind are seldom more than temporary. Sweat- ing, induced by muscular action, particularly by walking, with an additional quantity of clothing, rarely fails to give temporary relief, and has been known to remove the disease altogether by frequent and regular repetition of tbe exercise.* Sect. III.—Gout. Gout is a constitutional affection, depending on a peculiar diathesis, and manifesting itself in its regular form by external local inflam- mation of the fibrous structures and fever of the synochal grade. In relation to its symptoms and progress, however, it is subject to certain prominent modifications, which have given rise to its di- vision into the three following varieties: acute, chronic, and retro- cedent gout. 1. Regular gout.—The acute or regular form of the disease oc- curs in paroxysms at longer or shorter intervals, leaving the patient in an apparently perfectly healthy condition during the intermediate periods. Occasionally the paroxysm comes on suddenly, without any warning of its approach ; but, in by far the greater number of instances, it is preceded by various premonitory symptoms : such as * Marcet, Lond. Medico-Chirurg. Transactions, 1812. GOUT. 399 disturbed digestive function ; a peculiar, uneasy, anxious, and empty feeling in the pit of the stomach ; a sense of tension, and weight in the abdomen ; an irritable state of the bladder; flatulency and acid eructations; costiveness; a white tongue ; giddiness; great lassitude; yawning, and stretching of the legs; drowsiness, with disturbed sleep, depressed spirits, and debility. In some instances, a disagree- able itching of the skin occurs a few days previous to the attack • and in most cases, the urine acquires a deep red colour. Some per- sons experience a feeling of numbness and formication in the lower extremities, with coldness of the feet and legs, before the paroxysm comes on. Sometimes the appetite is depraved and voracious, at- tended with occasional nausea and vomiting. Not unfrequently blennorrhoeal discharges occur from the bowels or bladder, or a copious secretion of mucus takes place in the bronchia. Some pa- tients experience a sensation as if warm, or more commonly cool air were passing in a gentle stream, up and down the extremity, which is about to become the seat of the disease. According to Van Swie- ten, the venereal propensity is sometimes particularly urgent just before the accession of the attack.* Of all these symptoms, the dyspeptic, or those indicative of gastric disturbance, are the most common precursors of the gouty attack. The duration of this pre- monitory period is very indefinite, and varies from a few hours to many days. The attack generally comes on at night. About two or three o'clock in the morning, the patient is roused from sleep by a severe pain in the ball of the great toe, or in the heel, or instep of one foot. Chills or rigors speedily ensue, terminating after a short period, in febrile reaction. The pain now becomes more and more severe; the patient is restless, his skin hot and dry, and the pulse frequent, full, and generally hard. About five o'clock in the morning, some remis- sion in the general and local symptoms usually occurs, with more or less profuse perspiration, and a short interval of imperfect rest is obtained. In some instances, the pain and fever continue with una- bated violence, until about the middle of the following night, when they gradually decline, under a moderate flow of sweat —the patient sinking into a quiet sleep towards morning. In very severe attacks, however, no obvious remission of the symptoms take place, until the third or fourth morning. In all instances, however, the sufferings of the patient are greater during the fore part of the night than in the day. When the affected part is examined in the morning after the accession of the paroxysm, it is found swollen, red, and the veins at the foot greatly distended with blood. The swelling is of an oedematous character, more especially after the disease has continued a few days. The tenderness of the inflamed joint is so great, that the weight of the lightest bed-clothes is often insufferable, and every motion or agitation of the limb excites the most torturing pains. In slight attacks, the constitutional symptoms are moderate ; but, in the severer cases, the febrile excitement is always very considerable. * Comment., vol. xiii, p. 44. 400 GOUT. The digestive functions are almost invariably conspicuously de- ranged ; the tongue is furred, the appetite wholly depressed, the thirst urgent, the bowels constipated, with colic pains, and a sense of uneasy weight in the epigastrium. An unusual degree of nervous irritability prevails during the paroxysm, the patient being generally fretful, irritable, and difficult to please. The duration of a first paroxysm of the disease is seldom less than five, or more than nine days ; but in subsequent attacks, it is often protracted beyond the second, or to the end of the third week. After the disease has subsided in one foot, it occasionally attacks the other, and passes regularly through its course, as in the first instance. The patient is usually left in a much better state of health, after the complete subsidence of the paroxysm, than he enjoyed previously to the occurrence of the attack. His mind and body are, as it were, renovated ; his appetite and digestion are good, and his powers, both mental and corporeal, more lively and energetic. Sooner or later, however, according, to the degree of constitutional predisposition, and the habit of living, the paroxysm is renewed. At first, the return of the disease is generally at long intervals; in some cases, only after a period of three or four years; though more commonly, its first visits are annual. The intervals of its recurrence gradually become shorter, in proportion as the constitutional energies are enfeebled by its attacks, until at last, " the patient is hardly ever tolerably free from it, except perhaps for two or three months in the summer." Cullen. The periodicity of gout is occasionally very regular. Scudamore mentions an instance where the attack returned regularly on the 12th of April, for three years in succession. Such a strict periodical recurrence of the disease is, nevertheless, very rare. At first, the inflammation occurs generally only in the feet, but when, by the frequent recurrence of the attacks, the system is weak- ened, and the gouty diathesis strengthened, several joints sometimes become simultaneously affected, or the inflammation passes succes- sively from one external part to another, in the same paroxysm. (Scudamore.) " The external appearances of the disease," says Scu- damore, " vary considerably, according to the situation and particular texture of the part which is affected. The redness of surface, together with the oedematous swellings, is most remarkable on the great toe, on the foot, the back of the hand, and at the elbow; while at the ankle, knee, and wrist, the increased bulk is produced chiefly by the distension of the bursas, and the sheaths of the tendons, and takes place often with little change in the natural colour of the skin." The sequelx of gout are various, and sometimes of a very distress- ing character. The liver always suffers more or less functional dis- order, and in some instances, undergoes structural derangement. The stomach seldom escapes becoming permanently debilitated from repeated attacks of the disease. The local effects of repeated attacks of gout are sometimes less distressing than the general affections which result from it. The tendons about the affected parts become hard and knotty, and in some instances complete anchylosis ensues. Chronic gout.—When, from the repeated attacks of the acute form GOUT. 401 of the disease, the system becomes enfeebled, or where there is an original deficiency of constitutional energy connected with the gouty diathesis, the disease does not manifest itself by paroxysms of acute inflammation, but by chronic wandering, and irregular pains, bearing much resemblance to chronic rheumatism. The pain in chronic gout is usually but moderate during the day, the patient experiencing only a sense of alternate heat and coldness in the affected parts; at night, however, it is generally severe and aching. A feeling of numbness and weight is experienced in the diseased parts, and slight cramps are apt to occur during the forepart of the night, and the sleep is restless, and interrupted by sudden start- ings. The affected joints retain their natural colour, or present only a slight purplish hue; but they become oedematous, tender, and more or less stiff; and the neighbouring muscles are weakened, and some- times diminished in size. The inflammation often passes successively from one joint to another, or it leaves the original seat, and fixes upon some distant joint, and after having remained there for a while, returns to the part it had left. There is rarely any very conspicuous fever; but the digestive and biliary organs are generally very prominently deranged. The dys- pepsia attending this form of the disease, says Scudamore, is parti- cularly characterized by great oppression, and flatulent distension of the stomach after a full meal, together with heartburn, and occasion- ally a sense of coldness in the stomach. The bowels are usually torpid, or affected with mucous diarrhoea; the urine is turbid; and often charged with mucus; the skin dry, contracted, and sallow ; the bilious secretion deficient; and both the animal and vital functions much impaired. The temper, in this variety of the disease, is always very irritable, dissatisfied, morose, irresolute, and sometimes gloomy or hypochondriacal. In some instances, pain is occasionally felt in the kidneys, or neck of the bladder, and gravelly matter is discharged with the urine. The local consequences of inveterate or chronic gout are often extremely distressing. The ligaments become thickened ; the bursas mucosae indurated and enlarged; and the tendons knotty, rigid, and contracted. In some individuals, strongly predisposed to the disease, earthy matter is deposited in the bursae, sheaths of the tendons, under the cuticle, and in the cellular membrane surrounding the affected joint. Mr. Brodie observes: " the effects of gout on the joints are very remarkable. The cartilages are absorbed ; the exposed surfaces of bone are entirely, or partially encrusted with white earthy matter, which I conclude to be urate of soda; and sometimes they have the appearance of being formed into grooves, as if they had been worn from their friction on each other." Retrocedent gout.— When the gouty inflammation, either of the acute or chronic form, leaves its external seat, and fixes on some internal organ, it constitutes what is termed retrocedent gout. This retrocession of the disease may depend either on a want of constitu- tional energy, or upon an accidental or habitual weakness of some internal organ; or finally, on cold, repelling, and debilitating appli- vol. i.—26 402 GOUT. cations made to the external gouty inflammation. The disease may be translated to almost every internal organ ; but the parts most commonly affected, are the stomach, bowels, brain, heart, and kid- neys. When an acute attack of gout passes to the brain, coma, furious delirium, or symptoms of apoplexy, speedily ensue. Paul- mier relates a case where the retrocession of gouty inflammation from the foot to the brain gave rise to peculiar visual illusions; the patient being harassed by a confusion of horrid and ludicrous sights, which were removed in a few hours by epispastics applied to the feet.* When the stomach becomes its seat, violent and often fatal spasm of this organ, or symptoms of acute gastritis, supervene. In the intestines, retrocedent gout generally gives rise to enteritis, or violent colic. If the heart becomes its seat, symptoms of angina pectoris, or more commonly protracted and generally fatal syncope occurs. When the disease passes to the lungs, it gives rise to violent and most painful asthmatic symptoms; in the kidneys it causes nephritis; and when it fixes on the neck of the bladder, the phenomena of vesical calculus ensue. It has been a subject of considerable controversy whether the in- ternal affection which arises from translated gout be of an inflam- matory nature, or whether spasmodic. It is probable, I think, that the metastastic affection may assume either character, according to the structure upon which it falls, or the peculiar habit of the system. In the stomach, it appears sometimes under the form of violent and rapidly fatal spasm; and in the brain, coma and convulsions; although in both organs the ordinary symptoms of inflammation often occur when invaded by the disease. In the atonic and obscure form of the disease, where the gouty affection is, as it were, floating about in the system, with an occasional imperfect manifestation of its presence in the joints of the extremities, the effects of its attacks on internal parts are not so violent and dan- gerous as those resulting from metastasis of the acute form of the disease, although often extremely distressing. Indeed, atonic, or irregular chronic gout, often fixes upon internal organs at once, and without the previous or concurrent appearance of external articular inflammation. It sometimes locates itself in the mucous membrane of the urethra, giving rise to a blennorrhoeal discharge, resembling gonorrhoea. In old and gouty habits, the mucous membrane of the bowels sometimes becomes affected with the gouty irritation, pro- ducing muco-purulent discharges from the rectum ;t and a similar discharge is still more common from the kidneys and bladders in such individuals. Haemorrhages from the nose, lungs, kidneys, and womb, have been known to arise from gouty irritation; and Richter observes, that haemorrhoids are particularly apt to occur in gouty habits.J Various cutaneous affections depend, sometimes, on a gouty con- dition of the system. Richter says, " there is a gouty itch, as well as * Diet, des Scien. Med., t. xix, p. 112. t Reil's Fiebrlehre, b. iii, p. 596. X Specielle Therap., torn, vi, p. 571. GOUT. 403 herpes, which- latter is apt to appear on the parts in which the gout is wont to appear, and particularly on the wrists and the ankles." Gilbert relates an instance in which a number of furuncles appeared, instead of a regular attack of the disease, in a person who had been long subject to hereditary gout.* Chronic gouty affection of the stomach may show itself by pyro- sis ; extreme sensibility of the stomach; bulmia; or total anorexia with gastralgia and flatulency. De Haen mentions a case, where the desire for food recurred at times so violently and suddenly, that if it was not immediately satisfied, severe pain in the stomach, with nausea and violent vomiting, speedily ensued. StoU relates an instance of spasmodic dysphagia from gouty irritation. Chronic gout, located in the bowels, sometimes gives rise to a colicky affection, with para- lysis of the lower extremities, strongly resembling colica pictonum. The genital organs are occasionally affected by chronic gout, giving rise to painful and protracted priapism, and pollutions. The uterus, too, often becomes the seat of gouty irritation, particularly about the period of the final cessation of the catamenia. " A state of chronic inflammation of the uterus ending in a kind of enlargement and indu- ration of this organ, is occasionally the consequence of this affection." (Richter.) Chronic pectoral affections are extremely common in old people who have been much afflicted with gout. Cough, dyspnoea, asthma, with copious mucous expectoration, or occasional violent and distressing sanguineous engorgements of the lungs, (apoplexia pul- monum,) are the usual occurrences in cases of this kind, It would seem, too, that retrocedent gout is not unfrequently the cause of hypertrophy, ossification, and other organic affections of the heart. (Kreysig.) Pott mentions a case of hydrocele, which disappeared on the occurrence of a regular paroxysm of gout; and it is stated by Musgrave, that chronic gout sometimes assumes the character of scurvy. There is, indeed, scarcely any form of acute and chronic dis- ease which may not arise from gouty irritation, and almost every organ or structure of the system may be the seat of its ravages. Diagnosis.—The only affection with which gout is apt to be con- founded is rheumatism ; and there exists, indeed, a very close resem- blance between them, although sufficiently diverse, in several essen- tial circumstances, to justify their being regarded as distinct forms of disease. The principal points of difference between these two affec- tions, have already been mentioned under the head of rheumatism, and need not therefore be repeated in this place. Causes.—Gout, unlike rheumatism, requires a peculiar constitu- tional habit or predisposition, before any exciting cause can develop the disease. This predisposition is frequently hereditary, and perhaps still more frequently acquired by certain habits of living. Where the predisposition is very strong, and this will generally be the case when it is derived from both parents, scarcely any precautions in avoiding its usual exciting causes are sufficient entirely to obviate some manifestations of the disease. It is asserted by some writers, * Diet, des Scien. Med., torn, xix, p. 117. 404 GOUT. that, however considerable the gouty predisposition may be, the dis- ease occurs but exceedingly seldom, and some assert never, before the age of puberty. Richter, however, affirms that the disease some- times, though indeed very rarely, occurs even in childhood. This predisposition does not manifest itself in early life, by any obvious defect of constitutional vigour or health. The children of gouty parents are as apt to be strong, robust, and to possess apparently as vigorous digestive and assimilative powers, as those born from parents of the most healthy habits. Barthez, however, observes that the hereditary predisposition to this disease is generally attended with a peculiar physiognomical expression, by which an experienced eye may detect its existence.* The age at which gout usually first shows itself, is between the thirtieth and fortieth year. Women are much less subject to this disease than men; and in its regular and acute form, located in the feet, it is almost exclusively confined to the latter sex. When gout does occur in females, it is almost always after the period of the final cessation of the menses, and in them it usually assumes somewhat of an atonic or irregular character. Hippocrates observes, that eunuchs are never affected with gout; an observation which is, however, contradicted by Dreysigt and others. The causes which are especially calculated to produce a predis- position to gout in habits free from hereditary diathesis favourable to this disease, are, the habitual and superabundant use of rich, nourishing, and strongly seasoned articles of food, particularly animal diet; and the free indulgence in vinous or fermented liquors, in con- junction with an indolent, inactive, and luxurious course of life. Vinous liquors are much more apt to lay the foundation of gout than distilled alcoholic spirits ; and of the former it would appear that champagne, claret and port, have a considerably stronger tendency in this way than Madeira, Lisbon, and sherry, "because in addition to their equal or greater heating effect, they give rise to more acidity in the primae viae." (Scudamore.) Dr. Rush, in refer- ence to the comparative tendency of wine and ardent spirits to pro- duce gout, observes that the effects of the latter are too sudden and violent to admit of their being thrown upon the extremities, and that they appear only in visceral obstructions, and a complicated train of chronic diseases. "The effects of wine," he says, "like tyranny in a well-formed government, are felt first in the extremities; while spirits, like a bold invader, seize at once upon the vitals of the con- stitution." Indolence, or an inactive course of life, contributes power- fully to the production of the gouty diathesis. Neither rich and high- seasoned food nor the free indulgence in vinous potations, is apt to produce the predisposition to gout where it is counteracted by a laborious or very active course of life. The principal exciting causes of gout are, intemperance in eating and in the use of spirituous liquors; suppression of habitual evacua- * Barthez. Trade des Maladies Goutteuses. Paris, an. 10. t Anfangsgr. der pract. Arzniew, p. 711, as quoted by Richter—Specielle Therapie, b. vi, p. 605. GOUT. 405 tions; violent or depressing mental affections; cold and humidity; redundancy of acid or bile in the primas viae; fatigue both of body and mind ; intense and protracted study ; external injuries; the abuse of mercurial remedies; excessive evacuations, particularly sanguine- ous discharges; excessive venereal indulgence ; and a sudden change from an abundant and nourishing to a spare and innutritious diet. Proximate cause.—In relation to the proximate cause of gout, a very great variety of opinions have been expressed by pathologists. The hypothesis which has obtained most credit, in reference to the pathology of this disease, is that which ascribes it to a peculiar morbific matter in the blood. It has been supposed to depend on an excess of uric acid in the system; since, according to the observa- tions of Wollaston, there always exists a redundancy of this acid in gouty persons. Berthollet thought that an excess of phosphoric acid constitutes the proximate cause of the disease—an opinion to which he was led from having observed that the urine of gouty individuals was much less charged with this acid during the absence of the active state of the disease than in healthy persons; but that it became abundant on the approach and during the continuance of the gouty paroxysm. Some have contended, that instead of a super- abundance of an animal acid in the system, the materia arthrilica is of an alkaline character. It is asserted by Petit that the perspi- ration of a gouty patient has been known to turn the tincture of violets into green colour.* The theory of Herrisant, and, in general, the identity of the nature of urinary calculi, and of gouty concre- tions, though apparently confirmed by the experiments of Scheele, has been fully confuted by Wollaston—since, from his experiments, it appears that gouty concretions always contain lit hate of soda, which, according to Fourcroy, never enters into the composition of urinary calculi.t Scudamore has entered into an elaborate experi- mental examination of the two former of these doctrines. In rela- tion to Wollaston's hypothesis, he ascertained by experiment, that the appearance and quantity of uric acid are always connected with, and proportionate to the unhealthy state of the chylopoietic func- tion, but neither necessarily nor regularly an attendant on gout. With regard to the opinion of Berthollet, his experiments show that, although an increased secretion of phosphoric acid in the urine occurs in the paroxysm of gout, yet the same takes place in other diseases; as, for example, in diseases of the liver, and in some forms of fever. It is evident, therefore, that the chemical products which occur in gout are various, and that they are to be regarded rather as the effects of a peculiar morbid condition of the organization, than as the proximate cause of the gouty phenomena—or as furnishing any evidence of a specific gouty matter in the system. (Richter.) Without, however, referring to any other doctrines on this head, it may be observed, that disorder and debility of the digestive func- tions are one of the most constant precursory, as well as concomitant * Diet, des Sciences Med., t. xix, p. 162. t Richter's Specielle Therapie, b. vi, p. 634. 406 GOUT. occurrences of an attack of this disease. From the constant attend- ance of this gastric disorder, Broussais and some other writers have been Jed to regard the disease as primarily located in the primas viae, and as depending on a peculiar irritation in the mucous membrane of the alimentary canal. The dynamic doctrines of Stahl, Cullen, Barthez, Sprengle and others, are even less satisfactory than those which place the proximate cause of the disease in some morbid dis- position of the blood. It can, nevertheless, scarcely be doubted, that some defect or derangement of the reproductive functions lies at the bottom of the evil; and that this primary dynamic disorder, in conjunction with the consequent humoral depravation, constitutes the fundamental pathological condition of the system in gout. Treatment.—The treatment of gout divides itself into that which is proper during the paroxysm, and that which is appropriate during the intervals of the fits. To obviate or postpone the recurrence of the disease after it has once made an attack, an abstemious course of digestible diet must be enjoined, and the use of wine and other fer- mented liquors interdicted. Various remedies have been recom- mended during the premonitory stage, with the view of preventing the development of the approaching paroxysm, or of moderating its violence—all of which, however, are much more apt to prove injuri- ous than beneficial, and ought to be rejected as hazardous.* During the attack of the disease, the general treatment must be more or less antiphlogistic, according to the degree of general phlo- gistic excitement present. Unless the system is very plethoric, and the habit vigorous and inflammatory, bleeding may be well dispensed with. Under no circumstances, indeed, can this evacuation be re- garded in any other light than a doubtful auxiliary; and when carried to a great extent, may do serious injury by favouring metastasis to internal organs. It is true, instances are mentioned where the local affection was speedily removed and by prompt copious abstractions of blood, without any immediate evil consequences; but the cases where this practice was productive of dangerous effects, are suffi- ciently numerous to demonstrate its dangerous tendency when very actively employed. I am well aware that there are eminent authori- ties on the side of decisive blood-letting in this affection. Heberden, Rush, and Hamilton, insist strongly on the propriety of venesection m gout; but the present sentiment of the profession is opposed to this measure as a principal remedy; although, moderately employed, it is generally admitted to be useful under symptoms of high vascular excitement. Cathartics are decidedly beneficial in the attack of regular gout. * The following means have been advised in the forming stage of the disease, in order to moderate or prevent the paroxysm. Emetics, (Chalmers;) active catharticis, (Musgrave :) vegetable bitters, iron, and high-seasoned food, (Grant;) Dover's powder or antimonial wine with opium, (Fothergill;) large doses of musk or castor, (Williams;) gratiola, (Wolff;) bleeding from the foot, (Gilbert;) the application of very cold water to the feet, (Giannini;) the internal use of iced- water, (Barthez;) &c. GOUT. 407 The alimentary canal is always more or less loaded with dark-coloured, vitiated, and irritating matters, which should be as speedily evacuated as possible. Scudamore recommends the following pills—a combina- tion which I have used with very good effect.* He advises the ex- hibition of cathartics and diuretics conjointly, as particularly useful in the gouty paroxysm. "I have experienced the most remarkable success," he says, "from a draught composed of magnesia gr. xx; sulphat. magnesias 3iss; vin. colch. siss, with a little sweetened water. This draught should be repeated at intervals of four, six, or eight hours, according to the freedom of its operation and the urgency of the symptoms." The bowels should be kept freely moved through- out the paroxysm.t Emetics also have been recommended in the treatment of gout; and where the symptoms of redundancy of acid, or bile, or other offending matters in the stomach, are unequivocal in the commence- ment of the disease, advantage may, no doubt, be obtained from the administration of an emetic. As a general rule, however, emetics are inappropriate in this affection. They are indicated when there is much nausea, vomiturition, acidity in the stomach, with a furred and foul tongue, or where the disease supervenes soon after a hearty meal. Ipecacuanha should be employed for this purpose in preference to antimony. For the purpose of keeping up a gentle diaphoresis, we may em- ploy opium in combination with calomel and tartar emetic with much advantage, after the bowels have been freely evacuated by purgatives. A grain of opium, with the same quantity of calomel and one-tenth of a grain of tart, antim., may be given every four or six hours— assisted by copious draughts of infusion of elder flowers, or of eupa- torium perfoliatum. I have used the diaphoretic mixture, given at page 174 of this work, with the addition of a drachm of laudanum, with excellent effect. To moderate extreme suffering from the gouty inflammation, and to procure the patient some repose, opium, under proper management, is both a safe and a highly useful medicine. " On many occasions," says Scudamore, " when the patient has described the pulsatory throbbing of the inflamed part to resemble almost the successive blows of a hammer, when the heart has been in inordinate action, and the inflammatory diathesis has appeared alto- gether urgent, I have stood by the bedside and witnessed the happy power of a free administration of opium, in causing an abatement of the action of the vessels, and producing universal tranquillity in a short time." I have myself employed opium in this affection with the hap- * R.—Extract, colocynth. compos, ^ss. Calomel gr. xv. Tart, antimon. gr. i.—M. Divide into sixteen pills. S. Two or three to be taken on going to bed. t Boerhaave, Warner, and some other writers, reject purgatives wholly from the list of remedies proper in this disease, but their apprehensions in this respect are without foundation. 408 GOUT. piest effect. Not only is the extreme pain allayed, but the sympathetic febrile excitement also is generally conspicuously moderated by full doses of this narcotic. The bowels should be freely evacuated before recourse is had to this medicine. It may be given in doses of one grain, either by itself or as mentioned above, with calomel and tart, antim., every hour or two until the local pain is allayed. When opium dis- agrees with the stomach, the black drop, or the liquor opii sedativus of Dr. Battley, should be employed.* A great number of specifics and nostrums have at different times acquired a temporary reputation for their usefulness in this disease; of which, however, a few only need be mentioned. The colchicum autumnale, which would seem to be the hermo- dactyl of the ancients, is now universally admitted to be an article of great powers in removing gouty inflammation. It is not, however, admitted on all hands to be a very safe remedy; for it is asserted by some, " that it is apt to leave the predisposition to the, disease much stronger in the system; to lead to the still more calamitous, because still more constant, pains of the chronic form of the disease." (Scuda- more.) That the objections which have been urged against this article are altogether unfounded, I am not disposed to affirm ; but I think it highly probable, that much of the harm which has been ascribed to it has arisen from the improper or inordinate use of the remedy. I have used it in about a dozen instances with marked advantage, and so far as I have ascertained, without any prejudicial consequences whatever. Even Scudamore, whose objection to this article I have just quoted, observes, that under judicious management, it may be employed with perfect safety, and almost always with decided benefit. He gives it with magnesia and Epsom salts, according to the formula above referred to in page 174. I have usually directed from 30 to 50 drops of the vinous tincture with about 20 grains of magnesia, to be taken every six hours until it acts on the bowels. When it produces nausea, or other unpleasant sensations in the stomach, its use must be discontinued. The eau medicinale is a celebrated nostrum, which has been ex- tensively used in France ; and its powers of shortening the paroxysm are said to be surprisingly great. It is now generally admitted, how- ever, that in its ultimate consequences, it often proves highly injurious. When first used, it rarely fails to remove the gouty inflammation speedily; but its powers in this way are gradually diminished by repetition—producing at last great derangement of the digestive func- tions, permanent nervous irritation, giddiness, trembling, coldness, and oedema of the extremities, and other manifestations of infirm health. The tincture of white hellebore and laudanum has also been found promptly efficient in removing gouty inflammation, but it is said to be as pernicious in its consequences, and even more so, than the eau medicinale. Local remedies.—Various local applications have been employed * Opium is very favourably mentioned as a remedy in this disease, with the view of moderating the patient's sufferings, by Sydenham, Warner, and Richter. GOUT. 409 in the treatment of gouty inflammation ; but the majority of them are useless, and indeed often prejudicial. Neither leeching, nor blistering, nor warm pediluvium, appears to be calculated either to relieve the pain, or to promote the resolution of the local affection. Leeching even sometimes increases the pain. Some have advised the application of cold water to the inflamed joint—a measure which will, indeed, often moderate the pain and inflammation, but its particular tendency to cause a retrocession or translation of the disease to internal organs, renders it objectionable.* Scudamore observes, that the best local applications are such as are volatile and stimulating. He strongly re- commends a liniment composed of one part of alcohol and three parts of mistura camphorata, which is to be applied to the affected part in a lukewarm state, by means of several folds of linen strips saturated with it. I have employed this lotion in several instances with decided benefit. Its good effects were manifested by a speedy mitigation of the heat and pain of the affected part. The application of ether will also afford relief by its rapid evaporation, and consequent subduction of the heat and local excitement of the inflamed joint.t Wrapping the part in flannel was formerly regarded as the most safe and beneficial application; but "flannel and patience" have very properly grown out of fashion; for this application tends to protract the paroxysm, and to aggravate the sufferings of the patient, without affording any peculiar advantages as to the future health of the patient. Where there is slight or incomplete development of the gouty inflam- mation in the extremities, with a tendency to retrocession, benefit may, no doubt, be derived from the application of flannel or cotton to the part; but, in the regular and fully developed attack, it is at best use- less, and often distressing.^ During convalescence after an attack of gout a temperate and moderately nourishing diet, with regular exercise and the occasional use of mild laxatives, should be enjoined. When the biliary and digestive functions remain disordered, which is very commonly the case after violent and protracted paroxysms, small doses of blue pill in the evening, with an occasional laxative and a weak infusion of colombaor gentian, in small but repeated doses during the day,should be used.§ To remove the protracted swellings which sometimes re- * The practice of applying cold water to the indamed joint in gout is recom- mended by Hippocrates— (Aphor., sect, v.)—Kinglake employed cold poultices. Med. and Phys. Journal, No. 24. t [I have often seen a strong solution of lunar caustic (40 grs. to the §i) applied over the inflamed parts by a swab, so as to blacken the cuticle, give immediate and effectual relief.—Mc] X A great variety of other local remedies have been favourably mentioned— namely, the warm steam bath, (Percy;) the split leaves of the cactus crocus, em- plast. hyoscyam., spread on odedsilk, (Thdenius;) emplast. opii; cataplasms of conium, belladonna and hyoscyamus, and moza. $ As an aperient during convalescence from gout, Warner's gout cordial is an excellent remedy. The formula for making this tincture is as follows : R.—Rhu- 410 GOUT. main, stimulating liniments may be usefully employed; or, as Scuda- more recommends, a flannel roller applied to the affected part. The remedies or prophylactic means that have been recommended during the intervals of the paroxysm, with a view of moderating the gouty diathesis, or of preventing the recurrence of the disease, are very numerous. Little or no dependence, however, is to be placed on any measures in this respect, except on such as are calculated to restore the healthy action of the stomach, liver, and skin ; and espe- cially on the adoption of proper regulations, with regard to diet and exercise. Abstinence from high-seasoned and very nourishing diet, and from all kinds of fermented liquors, with regular exercise in the open air, a constant attention to the maintenance of the healthy action of the bowels, liver and skin, by the occasional use of laxatives, blue pill, and weak infusion of some of the tonic vegetable bitters; and the wearing of flannel next to the skin, will, perhaps, do all towards resisting the progress of the disease that can be effected by remedial means. According to the experience of Scudamore, the ammoniated tincture of iron, commencing with 20 drops twice daily, and gradually increasing the dose to 60 drops, is an excellent tonic during the intervals of the gouty paroxysm. In the treatment of the chronic form of the disease, the principal attention must be directed to the chylopoietic organs. A light and digestible diet, with an occasional blue pill in the evening, followed in the morning by a gentle laxative, are among the most useful reme- dial measures in this variety of the disease. To relieve the nervous irritation and pain, generally so distressing during the night, we may give one or two grains of opium, or from 15 to 20 drops of black drop at bedtime. Scudamore recommends lactucarium and stramo- nium in combination, as a very useful narcotic in such cases. Opium, in union with camphor, forms also an excellent anodyne in instances of this kind. The carbonate of ammonia, or from 20 to 30 drops of a solution of camphor in sulphuric ether, (siii of camph. to gi of ether,) or warm ginger tea, may be usefully administered, to relieve the spasmodic and nervous pains in the stomach, which are so com- mon in the chronic form of gout. A vast variety of remedies have been recommended for the removal or mitigation of chronic arthritic affections. Amongst these, however, there are very few that are worth being mentioned. Gum guaiacum; ol. terebinth; calamus aromaticus, (Rave, C. L. Hoffman;) and particularly the vegetable bitter tonics; aconitum, (Richter;) the bark of the prunus padus, (Horn's Archiv., 1812 ;) chalybeates ; herba rhododend. chrysanthi; belladonna; mercurial remedies ; and the use of sulphurous mineral waters, are the principal articles of this kind. Rave, a German writer, speaks in very favourable terms of savin (juniperis sabina) in chronic gouty inflammation Of the joints.* I have known much barb %i, senna ^ss, saffron 3, liquorice root 31V, raisins Ibi, brandy BSiii. Digest for a week, and strain. * Beobachtungen und Schliisse aus der praktischen Arzneywissenschaft. Von Alexander Rave. Munster, 1796. GOUT. 411 benefit derived from this article in chronic or subacute arthritic affec- tions, more especially in subacute rheumatic inflammation. Rave recommends the following formula for taking the savin.* In an atonic, torpid, or sluggish state of the system, with chronic gouty symptoms, the following composition, recommended by Quarin, will sometimes act very beneficially.t Alkaline remedies have also been supposed peculiarly adapted to counteract the gouty diathesis, but they appear to be of little or no value in this respect. Formerly the liquor anti- arthriticus Elleri was much in vogue as a remedy in chronic gouty affections. It consists of equal parts of sulphuric ether and aq. am- nion, succinata. The dose is from 30 to 40 drops. When the gouty inflammation leaves its external seat, and fixes on some internal organ, prompt and active remedial measures are necessary to obviate the immediate danger. Cullen recommends heating and stimulating remedies in retrocedent gout; where the disease attacks the stomach, this, without doubt, is often the best practice. Laudanum in large doses, (from 80 to 100 drops,) with warm spiced brandy, should be freely administered; and a large sinapism applied over the region of the stomach. Opium, in the form of tincture, is a most valuable medicine in cases of this kind. Even where the translated affection assumes the character of acute gastritis, and where the aromatic and diffusible stimulants are im- proper, the greatest relief will often follow the exhibition of large doses of this narcotic. When the brain becomes the seat of the trans- lated disease, stimulants and opiates are inadmissible. In such cases, our principal reliance must be placed on the speedy and copious abstraction of blood, together with the use of active mercurial cathar- tics, cold applications to the head, and sinapisms to the feet. In all instances of translated gout, stimulating or rubefacient applications to the feet are decidedly indicated. Irritating purgative enemata also are useful, as well as cupping and leeching over the region of the affected organ. * R.—Herb, sabin.recens. gii. Tinct. antimon. acris. gvi.—M. Digere per 3 vel 4 dies. Or, R.—Pulv. hb. sabin. recens. gss. Antim. crud. gr. xii. Flor. sulph. gr. xv. Camphor, gr. iv.—M. f. pulv. pro. dos. This dose is to be taken twice or thrice daily. t R.—Flor. sulph. %i. Resin, guaiac. gss. Antim. crude ^iii.—M. f. pil. pondere gr. iii. S. Take from six to eight pills three times daily. 412 CATARRHAL OPHTHALMIA. CHAPTER XVI. ON THE INFLAMMATORY AFFECTIONS OF THE EYES. 1. Catarrhal Ophthalmia. This is the most common form of ophthalmia in adults, and proceeds, as its name imports, from the influence of atmospheric vicissitudes, and especially from cold and damp night air. The in- flammation in this variety of the disease is confined chiefly to the conjunctiva and the meibomian glands. The patient complains of pain, intolerance of light, and a constant sensation of sand in the eye —which latter feeling may, according to Mr. Mackenzie, be regarded as a diagnostic symptom of this variety of ophthalmia.* In mild cases, the redness of the eye is not very great, and is most conspi- cuous in the conjunctiva lining the eyelids. The flow of tears is always much increased ; and in severe cases, the secretion often be- comes opaque and purulent. Chemosis sometimes takes place in very violent instances, and the cornea may burst and destroy vision. The headache, in this variety, is seldom very severe, and the febrile ex- citement is generally mild, and in slight cases altogether wanting. Treatment.—In mild cases of this variety of the disease, general blood-letting is rarely necessary or useful. In instances attended with considerable constitutional irritation, a sufficient quantity of blood should undoubtedly be drawn, to moderate the excessive mo- mentum of the circulation. Leeching rarely affords any decided advantage ; when local depletion is desired, cupping on the back of the neck and over the temples is preferable. Mr. Travers condemns scarification of the conjunctiva, and bleeding from the angular vein, in the acute form of the disease, although highly beneficial in the chronic. Nevertheless, when chemosis occurs, and the discharge becomes puriform, considerable advantage will, in general, result from scarifying the conjunctiva of the eyelids. " One or two deep incisions being made along the inner surface of the upper or lower eyelid, a very considerable discharge of blood will immediately take place, and prove a valuable means of cure in cases of this kind. The eyelid, after the incision, ought to be alternately averted and per- mitted to return to its natural position, by which means the divided vessels are refilled, and thus a continued flow of blood will be pro- duced." (Mackenzie.) In cases of this character, considerable benefit often accrues from the use of nauseating doses of tartrate of antimony, given at short intervals, so as to keep up a continued and uniform impression. * Med. and Phys. Journal, No. 4, 1826. CATARRHAL OPHTHALMIA. 413 Cathartics are indispensable in this affection. The bowels must be freely opened by a full dose of calomel and jalap, or by active doses of the neutral purgative salts, and kept in a loose state through- out the course of the disease. The usual astringent lotions do no good in this variety of the dis- ease ; indeed they often prove manifestly prejudicial. The solutions of sulphate of zinc or of acetate of lead, so commonly used in inflam- mations of the eye, seldom fail to increase the redness of the con- junctiva and the sensation of sand in the eye. The same observation applies to cold applications; for, although they generally produce temporary ease, " they are followed by reaction, with an increase of heat and pain." (Travers.) In the acute stage of the inflammation, ; benefit will frequently arise from the use of warm soothing fomenta- ' tions to the eye. A weak infusion of poppy, or simply warm water and milk, may be used for this purpose.—Emollient and soothing Avarm applications must not, however, be continued too long; for : they tend to relax and to produce oedematous elevation of the con- 'i junctiva. When the disease early assumes an atonic or almost solely congestive character, a few drops of the vinous tincture of opium, or of solution of zinc, or nitrate of silver, will often afford much relief. The nitrate of silver is decidedly the most effectual local application in this variety of ophthalmia. Four grains of this article dissolved in an ounce of distilled water, forms a solution of a proper strength; " a large drop of which is to be applied to the eye by means of a camel- hair pencil. The instant that it touches the eye, the salt is decom- posed, and the silver precipitated over the conjunctiva in the state of a muriate."* An abatement of the peculiar sensation of sand and of the inflammation, almost uniformly soon follows the application of this solution. I have myself employed the nitrate of silver in this way with almost uniform advantage. Mackenzie recommends also a solution of one grain of corrosive sublimate in eight ounces of water as a collyrium, to be used, milk- warm, thrice daily for fomenting the eyelids by means of a fine piece of linen, and allowing a few drops to pass into the eye. In cases of great severity, where the secretion is puriform, he directs " this collyrium to be injected over the whole surface of the con- junctiva, and especially into the upper fold of this membrane, by means of a syringe." An ointment made " by levigating twelve grains of red precipitate till they become an orange-coloured impalpable powder, to which an ounce of fresh butter is to be added, forms also a very useful application in this variety of ophthalmic disease." A very small por- tion of this ointment is to be applied along the edges of the eyelids at night on going to bed. Kopp speaks very favourably of the tincture of galbanum as a local application in ophthalmic inflamma- tion. A compress of linen is to be moistened with this tincture and laid over the closed eyelids. I have used this application with * Mackenzie, loc. citat. 414 RHEUMATIC OPHTHALMIA. marked benefit in several cases, after the acute stage of the inflam- mation had in a degree subsided. In some instances of a general irritable habit of body, the ophthal- mia will continue to grow worse under the ordinary depletory mea- sures, " the iritability increasing as the strength fails." In cases of this kind recourse must be had to calomel and opium in combina- tion, or opium with small doses of tart, antimon. or ipecacuanha. From three to four grains of Dover's powder, with the sixth of a grain of calomel, may be given every three or four hours, at the same time that the above exciting applications are made to the eye. Blistering on the back of the neck, particularly after proper depletion, will almost always assist materially in the reduction of the inflammation. In violent and protracted cases of the disease, the inner surface of the upper eyelid sometimes becomes rough, with a species of hard, fungoid elevations, resembling a state of sarcoma of the conjunctiva. Where this occurs it should be lightly touched with lunar caustic or a piece of sulphate of copper—the eyelid being held up from the eyeball for a minute or two after the application. Ophthalmia sometimes assumes a strictly periodical form. The attack in such cases is usually attended with intense suffering; and under the usual antiphlogistic plan of treatment, is apt to continue a very long time. In instances of this form, leeching, blood-letting, and cooling applications never fail to do harm. The appropriate means consist of the same remedies that are employed in intermitting neuralgia, or in the ordinary intermitting fever; and there can exist but little doubt that all these forms of periodical disease are congene- ric affections. Quinine, bark, and arsenic, will, in general, speedily arrest the progress of the present variety of ophthalmia.* 2. Rheumatic Ophthalmia. This variety of ophthalmic inflammation is chiefly characterized by violent circumorbital pain, extending to the temples, teeth, lower jaw, and internal ear. The pain is continuous, with occasional fits of aggravation, and is almost always much more severe at night than during the day. The white of the eye. is of a yellowish-red tinge, terminating abruptly at the cornea—which latter becomes dull, cloudy, and as the disease advances, more opaque in the centre than at the circumference. According to the observations of Tra- vers, "rheumatic ophthalmia presents a zonular arrangement of the vessels, more or less cloudiness of the aqueous humour, and a pupil displaced or drawn a little to one side." The flow of tears is at first diminished ; but in the course of the disease it becomes copious. In most instances, slight abrasions of the conjunctiva and cornea occur; but these are generally so minute and superficial as readily to escape observation, unless closely inspected. In violent and protracted * For an interesting case of this kind, see Journal Complement., Jan., 1830. See also Med. Chir. Rev., March, 1830. PURULENT OPHTHALMIA. 415 cases, the cornea is sometimes destroyed by ulceration, and pus is secreted within the chambers of the eye. The inflammation, in this variety of the disease, is confined chiefly to the fibrous structure of the eye and of the surrounding parts; and partakes in this respect of the character of rheumatism. It is excited by the same causes that give rise to the catarrhal variety; and occurs most commonly in persons of an arthritic or rheumatic diathesis. It is also particularly apt to occur from the influence of cold while the system is under the operation of mercury, or soon after the mercurial action has subsided. " It is often seen in com- pany with, or following gonorrhoea, eruptions, or sore throat of a pseudo-syphilitic character, and the pains are allied to those which succeed to the exhibition of mercury."* Treatment.—Bleeding very rarely affords any obvious advan- tages in this variety of ophthalmia. When the pulse is very active, it should, nevertheless, be moderated by venesection, in order to lessen the general phlogistic diathesis, and thereby favour the bene- ficial operation of the more appropriate remedies. Much advantage may sometimes be derived from one or more antimonial emetics in the early stage of the disease; and active purgatives are equally im- portant. After the alimentary canal has been evacuated, we may exhibit a solution of tart, antimon. in nauseating doses, every two or three hours; or antimonial powder in combination with opium and calomel, so as to keep up a uniform, continued, moderate diapho- resis.t I have known much good done in this variety of the disease by repeated small doses of Dover's powders. Cupping or blistering the nape of the neck is a useful auxiliary; and fomentations with an infusion of poppy heads always mitigates the pain very considera- bly. One of the most soothing applications to the eye, is a few drops of an aqueous solution of opium put into it several times a day, or a solution of the sulphate of morphia. Puncturing the cor- nea, so as to give exit to the aqueous humour, is almost always soon followed by an abatement of the inflammation and pain. The usual astringent and exciting collyria are wholly inapplicable in the treat- ment of this affection, and almost uniformly do injury. Mr. War- drop recommends the internal use of cinchona in very small doses, (from five to eight grains,) if the tongue remains white after the bowels have been freely evacuated. Would not the tincture of col- chicum be beneficial in this affection ? 3. Purulent Ophthalmia. Acute suppurative inflammation of the conjunctiva is the most dangerous variety of ophthalmia, and generally the most difficult to manage. It occurs, however, under every grade of violence, from a mild and simple to a most severe and rapidly destructive affection. * Travers—A Synopsis of the Diseases of the Eye, &c, p. 129. t R.—Pulv. antimonialis9i; calomel gr. iii; pulv. opii gr. iiss.—M. Divide into nine equal parts. Take one every three hours. 416 PURULENT OPHTHALMIA. The severer cases come on suddenly, and are from the beginning at- tended with very severe darting pains through the eye. The eyelids swell rapidly, and often to an enormous extent—the upper one being often so much enlarged as to rest upon the cheek. The conjunctiva also becomes so much swollen by infiltration and distension of its vessels, as to rise up in an annular mass of red spongy granulations, overlapping the cornea so as almost to conceal this part. A very copious purulent secretion from the inflamed conjunctiva takes place soon after the disease is developed—and which usually issues in large drops from under the swollen lids. The edges of the eyelids are sometimes so closely pressed against each other, as to confine the matter until it accumulates and distends the lids into a large round tumour, and at last bursts forth and runs down the cheek. The pain in the head is always extremely severe, and the whole system sympa- thizes strongly with the local affection—the accompanying fever being of a high synochal grade, suffering conspicuous exacerbations in the evening. Under judicious treatment, this severe form of the disease usually begins to decline about the third or fourth day, and gradually subsides until the health of the eye is restored. Cases of great severity, or where the treatment is inefficient or improper, often terminates rapidly in more or less disorganization of the eye and consequent loss of vision. Sometimes every part of the ball of the eye becomes disorganized by suppuration. Much more commonly, however, the consequences are not so destructive—a greater or less degree of opa- city and thickening of the cornea, or ulcerative destruction of this part, being usually the result of the inflammation. In some instances, ulceration of the proper substance of the cornea takes place beneath the conjunctiva—this membrane remaining entire. (Travers.) This "interstitial" ulceration of the cornea, says the author just referred to, may be either acute or chronic. The acute variety is often crescent- shaped, and passes nearly across the whole cornea. In consequence of the absorption or abrasion of the conjunctiva, directly over the ulceration ot the cornea, great pain is caused by the emotions of the upper eyelid. The chronic interstitial ulcer occurs in debilitated sub- jects, remaining often a long time, like a slight depression or excava- tion, on the surface of the cornea, the restorative action of the vessels of the part being inadequate to repair the lost structure. Gangrenous destruction of a greater or less extent of the. cornea may also take place in suppurative ophthalmia. In the milder variety of purulent ophthalmia, there is little or no danger of destruction of the cornea, unless injury be done by stimu- lating amplications. Mr. Travers says, "that a very slight haze of the cornea is the worst direct result of the mild form of the disease." In cases of this kind there is neither the intense pain nor the ex- cessive swelling of the lids, which characterizes the violent acute form of the complaint. There appear to be different varieties of suppurative ophthalmia, in relation to the exciting causes of the affection. The Egyptian ophihalmia, which is the most violent form of this disease, is ascribed to the combined effects of vicissitudes of atmospheric temperature and PURULENT OPHTHALMIA. 417 humidity, a hot wind loaded with fine particles of sand, and a bright and piercing light of the sun. A violent form of purulent inflamma- tion of the conjunctiva's also excited by the application of gonorrhceal matter to the eye; and, it is said, by metastasis of gonorrhceal inflammation from the urethra to the conjunctiva. Infants also are subject to purulent ophthalmia; but in them the disease is generally much less serious than in adults. Mr. Guthrie states that there are two varieties of infantile suppurative inflammation of the eyes: "one affecting the conjunctiva of the lids only, the other implicating the eyeball." I have repeatedly noticed these distinctions in the ophthal- mia of infants; and although little or no permanent injury need be apprehended from the former variety, I have found it even more difficult to subdue than the latter. Some writers attribute this affec- tion in infants to intestinal irritation from bile and sordes in the primae via?; but the opinion of its being almost universally the consequence of the direct application of some morbid secretion to the eyes at the time of birth, is, I think, by far the most probable. I have never known a single instance of this disease occurring in infants, soon after birth, where, upon inquiry, I did not learn that the mother had been affected with leucorrhosa, or some other morbid vaginal secretion. The fact, too, that the ophthalmic discharge in cases of this kind, is capable of exciting the same disease when applied to the eyes of others, furnishes a strong argument in favour of this etiology. Mr. Ryall, whose opportunities for observation on this subject have been very extensive, states that he has repeatedly known the ophthalmia excited in nurses, " by the accidental application of the matter from the infant's eyes to their own."* Purulent inflammation of the eyes occurs, no doubt, occasionally in infants as in adults, from cold, and various irritating causes, acting directly on the eyes; but this is, com- paratively, perhaps, but very rarely the case. Treatment.—In mild cases, where the swelling, pain, and purulent secretion are not great, general blood-letting is not often necessary. In the severer form of the complaint, however, prompt and very decisive bleeding is indispensable to success. In those vehement cases, where the swelling of the lids is very great, the purulent secre- tion copious, the pain intense, and the pulse hard and frequent, " the instant :relief," says Mr. Travers, "of a large venesection is inde- scribable. The pain is mitigated if not removed, the pulse softened, and the patient sinks into a sound sleep, and perspires freely. Upon inspection we observe the high scarlet hue and bulk of the swollen and fungoid conjunctiva sensibly reduced, and the cornea: has a brighter aspect."t It is frequently necessary to repeat the venesec- tion several times in the course of the first twenty-four hours, before permanent impression is made on the disease. In the disease as it occurs in infants, blood must be abstracted by a few leeches applied to the external angle, or under lid of the eye; and the eye should be frequently fomented with a decoction of poppy heads, a portion of which is to be injected under the lids to * Dublin Transactions, vol. iv. t Travers, loc. cit.. p. 265, vol. i.—27 418 PURULENT OPHTHALMIA. wash away the purulent secretion. Minute portions of calomel in union with ipecacuanha, or pulvis antimonialis, with an occasional dose of castor oil, should be given to infants labouring under this affection.* Topical bleeding, after the vigour of the arterial action has been moderated, by a very efficient abstraction of blood from the arm, will generally assist materially in reducing the local inflammation. From twenty to thirty leeches may be applied to each temple and around the eye. Blistering on the nape of the neck is also a very useful auxiliary: but decisive blood-letting should precede the application of the blister. One of the first and most important remedial mea- sures, is the exhibition of an active mercurial purge, and the bowels must be kept freely moved throughout the active stage of the dis- ease, by the daily use of full doses of one of the neutral purgative salfs. No nourishment, except the simplest mucilaginous fluids, or toast-water, must be allowed; and in very vehement and rapid cases, total abstinence from any nutrient ingesta should be enjoined, during the first two or three days. Along with blood-letting and active cathartics, nauseating doses of tartar emetic are, in general, deci- dedly beneficial. They should be given in small doses every hour or two, so as to keep up a continued impression on the stomach. During the acute period of the inflammation, emollient fomentations, such as warm Water, or infusion of the white poppy heads, will assist in mitigating the pain and promoting resolution; but all astringent and cooling applications are injurious. By the prompt and active employment of these antiphlogistic measures, the pain, irritation and swelling usually begin to subside about the third or fourth day, and the discharge becomes gleety at the same time that the conjunctiva assumes " a pale and flabby appearance." If, when the inflamma- tion has thus in part subsided, the cornea appear clear and bright, nothing need be apprehended as to the safety of the eye. Recourse must now be had to the exhibition of tonics and astringent and invigorating collyria. It would appear from the experience of Mr. Varlez, surgeon of the Military Hospital at Brussels, and of Mr. Guthrie, that the chloritret of lime forms the best local astringent application we possess iii this variety of ophthalmia. The former of these surgeons states that he has employed this article in more than four hundred cases of purulent ophthalmia with uniform success. After the local and general inflammatory condition is moderated by decisive depletion, a solution of this salt is to be applied to the in- flamed conjunctiva. He usually applied it in the proportion of a scruple to an ounce of distilled water; but when the inflammation continues, and when the patient bears it without complaining, it may be used, he says, to the extent " of three or even four drachms in the same quantity of water."! It has been found equally beneficial in the purulent ophthalmia of infants. In two cases of this variety * R.—Calomel gr. ii. Pulv. antimonialis gr. viii.—M. Divide into eight equal parts. Give one every four hours. t London Med. and Phys. Journ., 1827. PURULENT OPHTHALMIA. 419 of the disease, I derived the most signal advantage from injecting into the eye a solution of ten grains of the chloruret of lime to an ounce of water, repeated three times daily. The nitrate of silver, in the proportion of from two to four grains to an ounce of water, forms also an excellent local astringent in this affection. A few drops of this solution should be introduced into the eye twice daily. In the purulent ophthalmia of infants, after leeching, emollients, purging, and antimonials, have been employed, a weak solution of this article injected under the eyelids, is generally soon followed by the most favourable effects. Mr. Ryall says, that when the " dis- charge becomes profuse, assuming a greenish colour, all warm foment- ations and cataplasms must be laid aside, and a solution of the nitrate of silver, in the proportion of two or three grains of the mineral to an ounce of the distilled water, should be frequently and briskly injected between the lids."* Various other astringent and exciting lotions have been recommended after the acute character of the inflammation has been subdued.t A weak solution of alum, one grain to an ounce of water, is recommended by Travers. Others advise the application of alnm-curds confined between two folds of thin linen; and Ware speaks favourably of the following solutions : R.—sulphat. cupri. bol. arm. aa gr. viii; camphorae gr. ii; misce et affunde aq. bullient. § viii. At first a drachm of this solution must be mixed with an ounce of water, and injected forcibly under the eyelids; the strength being gradually reduced in proportion as the inflammation subsides. M. Jahn, of Meinengen, speaks very favour- ably of a solution of the chloride of gold, as a collyrium in the purulent ophthalmia of children. He says it is equally beneficial in scrofulous, gouty, and rheumatic inflammation of the eyes. He uses it according to the following formula.:): Tonics, such as the cinchona or quinine, with the sulphuric or nitric acids, must be employed to sustain the patient's powers, after the inflammation has been reduced, and the conjunctiva appears pale and flaccid. " If, when the lowering practice has been pushed to the extent of arresting acute inflammation, the patient being at the same time sunk and exhausted, the cornea shows a lack-lustre and raggedness of its whole surface, as if shrunk by immersion in an acid, or a gray patch in the centre, or a line encircling or half encircling its base, assuming a similar appearance, the portion so marked out will infallibly be detached by a rapid slough, unless by a successful rally of the patient's powers, we can set up the adhesive action so as to preserve in situ, that which may remain transparent. (Travers.) * Dublin Transactions, &c, vol. vi. t [The most prompt relief in cases of violent suppurative ophthalmia is afforded by passing a solid piece of lunar caustic rapidly over the inner surface of the everted tarsi, even in the acute stage.—Mc] X R.—Chloride of gold gr. ii.: distilled water |vi. Two or three drops of this solution must be instilled into the eye, and a compress wet with it applied over the eye. Rust's Magazine, vol. xxviii. 420 SCROFULOUS OPHTHALMIA. 4. Scrofulous Ophthalmia. This variety of the disease occurs most commonly in children, and is frequently the first manifestation of the scrofulous diathesis. Its most characteristic symptoms are : extreme sensibility of the retina to the impression of light; profuse serous secretion or flow of tears : and a muco-purulent secretion from the glands of the tarsi, which, during sleep, agglutinates the eyelids. The pain is not often great, unless a bright light is suffered to fall upon the eye; nor is the redness of the conjunctiva generally very conspicuous. In recent and acute cases, effusion of serum sometimes occurs around the cor- nea, " elevating the conjunctiva into a circular vesication, about a line or more in breadth, frequently occupying the entire margin of the cornea, and exhibiting a peculiar reddish-brown appearance."* In many instances of this acute character, minute vesicles appear scattered over the cornea and the conjunctiva of the sclerotic coat. " These pustules vary in size, according to the part or the conjunc- tiva on which they appear, being commonly smallest on the cornea, and increasing as they approach the angle where that membrane is reflected over the inner superficies of the lids, and may be con- sidered as a distinguishing symptom of this disease." (Jeffries.) These vesicles break, in some cases, and form ulcers; and if the inflammation be not checked, these ulcerations often gradually pene- trate deeper into the cornea, until they form an opening into the ante- rior chamber, and give exit to the aqueous humour. The disease does not, however, often occur in this acute form, the majority of instances met with being of a strictly chronic character, the vessels of the conjunctiva " remaining in a state of passive con- gestion and engorged with red blood," with small indolent ulcera- tions, or nebulae of the cornea, attended with a constant profuse flow of tears, and with such distressing intolerance of light, that the patient keeps the eyes constantly closed, and lies with the face downwards or keeps the hands continually applied over the eyes to exclude the light as much as possible. In many instances of this chronic variety of the disease, tinea ciliaris and lippitudo occur: small pustular ulcerations appearing along the roots of the eyelashes, from which a muco-purulent fluid exudes by which the edges of the eyelids are glued together; or the edges of the eyelids are red, and exco- riated. Mr. Christian, consulting surgeon of the Liverpool Ophthalmic Infirmary, has described a variety of scrofulous ophthalmia, which he calls porriginous, from the disease being usually preceded by a porriginous " eruption of pustules on the face and head." These pustules go through the various stages of suppuration, ulceration, and desquamation; and if the eruption in its pustular form, shall have disappeared before the inflammation of the eyes has com- menced, still there will almost always be found some traces of the * Cases of Surgery, &c. &c. By Henry Jeffries, Esq., senior surgeon to St. George's and St. James's Dispensary. Lond., 1820. SCROFULOUS OPHTHALMIA. 421 original disease in the form of scabs, or fissures behind the ears, at the commissures of the palpebral, or at the junction of the alas nasi with the cheeks."* This appears to be the same variety of scrofulous ophthalmia that has been described by Mr. AVardrop, under the name of exanthema- tous ophthalmia. Mr. Wardrop considers it as specifically distinct from the scrofulous form of the disease, though he admits that it very frequently occurs in subjects of a scrofulous habit. Neither the symptoms nor the treatment of this disease, however, differ so materially from those peculiar to scrofulous ophthalmia, as to justify the opinion that they are essentially distinct in their characters. « Eruptions of the scalp and discharges behind the ear, so frequent in children, are the affections with which this ophthalmia is most commonly connected. These diseases alternate with the disease of the eyes, the latter becoming affected when the eruption or discharge disappears; whilst, when either of these returns, the eyes recover. This ophthalmia also sometimes succeeds measles, scarlet fever, and other exanthematous diseases, but usually appears a considerable time after these affections have subsided. The symptoms of the exanthematous ophthalmia are Very characteristic ; for, besides being connected with eruptions and confined to young people, the excess- ive intolerance of light, the enormous secretion of tears, and the relief from forcibly squeezing the eyes, are symptoms quite peculiar. The patient can scarcely hold up his head, and if he is desired to open his eyes, he is affected exactly as if he were looking on a mir- ror, reflecting a bright sunshine, every attempt causing a profuse gush of tears, and being instantly succeeded by a violent and invo- luntary squeezing of the eyelids and knitting of the brows. He excludes all light, not only by holding down his head and squeezing the eyelids together, but by pressing a handkerchief firmly on them or by resting his face against a chair in some dark corner of the room. The intolerance of light is always more severe in the morn- ing ; but in the afternoon it sometimes remits so much as to allow the patient to open his eyes and see to a very considerable degree for some hours. The tears are of an acrid and irritating quality, so that the cheeks, alae of the nose, and lips, often become inflamed, swelled, and sometimes covered with pustules and cutaneous ulcera- tions."! Now this very graphic account of the symptoms answers in every particular to the descriptions given by authors of scrofulous ophthal- mia, and it certainly describes the disease which I have always con- sidered as the strumous, or scrofulous form of ophthalmia. Treatment.—General bleeding rarely becomes necessary in stru- mous ophthalmia. In recent and acute cases, however, leeching should be occasionally practised, until the pain, irritation and inflam- mation are moderated. Purgatives are indispensable in this affection, where the abdomen is tumid and tense, and the alvine discharges of * Glasgow Medical Journal, No. i. t Transact. Med.-Chirurg. Society of Edinb.. vol. ii. 422 SCROFULOUS OPHTHALMIA. an unnatural character. Calomel, combined with rhubarb or jalap, should be given every two or three days, in doses sufficient to cause pretty copious purging; or a few grains of calomel may be taken in the evening, and followed next morning by a dose of castor oil, or of senna infusion. This active course of purgation should be continued until the quality of. the alvine evacuations is manifestly improved. After this has been effected it will be sufficient, in general, to admin- ister a moderate dose of calomel and rhubarb every four or five days. In the more chronic form of the disease, also, active purgation is not, in general, beneficial. The bowels should be kept in a loose sta.te, however, by small doses of rhubarb or castor oil, or some other mild laxative. In many cases, there is considerable gastric disorder, the appetite being variable and capricious—sometimes much depressed and at others voracious. Where this is the case, emetics may be ac- counted among our most useful remedies. An aqueous solution of tar- tar emetic appears to be the best article for this purpose. The emetic may be repeated every third or fourth day, during the active state of the inflammation. To .promote the regular performance of the various excretory func- tions, small doses of calomel with pulvis antimonialis should be given at night, and where the system is very irritable, it will be proper to add a few grains of Dover's powder.* In a few instances I have derived conspicuous benefit from the use of sarsaparilla syrup, with a,very minute portion of muriate of mercury, but in many instances it failed entirely in doing any good. Where there is considerable general irritation, a solution of tartar emetic, given every two or three hours, in doses just sufficient to cause a slight nauseating im- pression on the stomach, will sometimes prove serviceable. After the alvine discharges have been brought to a healthy state, by the mer- curial purgatives, tonics will often afford much benefit. Wardrop recommends the use of the carbonates of soda or potass, either singly or in combination with small portions of rhubarb and the milder bitter infusions. " In some instances the mineral acids have been very useful, and also the preparations of iron." Quinine, however, is decidedly the most effectual tonic in this species of ophthalmia, after a proper course of mercurial purgation. In recent and acute cases, the diet should be simple and unirritating: such as liquid farinaceous preparations, or thin animal broths ; but in the more chronic variety of the disease, where the system is irritable and feeble, a more nour- ishing, though plain and digestible diet, must be allowed, in order to support the vigour of the system. Besides the general remedies already mentioned, various other articles have been recommended for the treatment of this affection ; amongst which the muriate of barytes and iodine, are the most important. Hufeland, in a small mono- graph on the use of the former of these articles in scrofula, relates some interesting examples of this variety of ophthalmia, which * R.—Calomel gr. iv. Pulv. antimon. ----Doveri, aa gr. viii.—M. Divide into four equal parts. SCROFULOUS OPHTHALMIA. 423 yielded to its powers.* I have employed this remedy in several cases with manifest advantage, and it appears to be worthy of more atten- tion than it has of late years received. The best mode of exhibiting this substance is in solution. A half a drachm of the muriate should be dissolved in an ounce of distilled water; of this solution, from thirty to sixty drops may be given three or four times daily to an adult; and for children, from one to two years old, the dose is from ten to twenty drops. Hufeland says, that the best vehicle for admin- istering this remedy, is a ptisan prepared of lig. guaiac.,rad. gramin., sarsaparilla, and dulcamara. I have also prescribed the iodine in a few cases, and its use was continued for more than three months, without having in a single instance obtained any perceptible advan- tage from it. Nevertheless, no inconsiderable number of cases have been reported in which this article is alleged to have proved de- cidedly beneficial, and from its well-known influence over strumous glandular enlargements, it is certainly entitled to attention as a re- medy in the present affection. Dr. Mackenzie, of Glasgow, speaks in the most favourable terms of the employment of the sulphate of quina in strumous ophthalmia. "After many years experience," he says, " in the treatment of strumous ophthalmia, and a trial of nu- merous and various internal remedies, I have found none so useful as quina. In most instances its effects have been very remarkable ; and, indeed, although I have met with a few cases which appeared to resist its beneficial influence, in most of the little patients to whom I have administered it, it acted like a charm. The dose which I employ is generally one grain thrice a day: and in very young chil- dren, half a grain ; and in adults two grains."! The Peruvian bark was strongly recommended by Fothergill and FordyceJ in the treat- ment of this affection, but its powers are vastly inferior, in this respect, to the sulphate of quinine. (Mackenzie.) With regard to the employment of collyria, and other local applica- tions, little of permanent advantage is to be derived from them. As palliatives, however, slightly astringent lotions, such as weak solutions of nitrat. argent., sulph. zinc, or sulphat. cupri, may be beneficially used where the inflammation and pain are considerable; or a decoc- tion of white poppy heads, " with a considerable quantity of extract of conium dissolved in it, (half an ounce to a quart of the decoction,) applied to the eye five or six times daily."§ I have found a solution of the nitrate of silver, in the proportion of four grains to the ounce of distilled water, to answer better than any other application of this kind. A few drops of this solution is to be instilled into the eye once * Darstellung der Medicinischen Kraft, der Salzsauren Schwererde. Von Dr. Christ. W. Hufeland. Berlin, 1794. t On the Utility of Sulphate of Quina in Strumous Ophthalmia, with Cases. By Wm. Mackenzie, one of the Surgeons of the Glasgow Eye Infirmary.—Glas- gow Med. Journal, No. 1. X Lond. Medical Observations and Inquiries, vol. i. $ Med. Chir. Rev., Dec, 1822, p. 538. 424 IRITIS. or twice daily.* Mackenzie speaks well of a collyrium composed of one grain of muriat. hydrarg. dissolved in eight ounces of water. When the 'disease is chiefly confined to the tarsi, (ophthalmia tarsi,) benefit may be obtained from the application of red precipitate oint- ment (fifteen grains to an ounce of lard), to the edges of the lids. Mr. Jeffries observes, that the small pustules which occur on the cornea and conjunctiva, should by no means be opened by art, as they are then apt to degenerate into ulcers, an occurrence which also greatly aggravates the pain, inflammation, and intolerance of light, and in- creases the risk of ultimate loss of vision from destruction or opacity of the cornea. Blisters very seldom procure any advantage in strumous ophthal- mia. Indeed, they often do harm, by the pustular inflammation which is apt to occur around the blistered part, and the consequent additional source of general and local irritation which is thus created. The insertion of a seton in the back of the neck is much more useful than vesication in such cases. After the acute character of the disease has subsided, the establishment of such a drain will almost always pro- duce the most favourable effects. In four cases which had resisted for many months the ordinary remedies, the disease gradually disap- peared entirely under the influence of a seton in the nape of the neck. 5. Syphilitic and Strumous Iritis. Inflammation of the iris may be produced by various causes, but its occurrence from syphilis is incomparably the most frequent. A vascular zone around the margin of the cornea, attended with cloudiness of the humours; constriction of very limited and sluggish motion of the pupil; great intolerance of light; obscure vision; a continued deep-seated aching pain in the globe of the eye, forehead, and circumorbital parts; and the appearance of very fine red lines and specks upon the iris, are the principal phenomena characteristic of this variety of ophthalmia. In the progress of the disease, adhesion takes place between the fibres of the iris, " the pupil losing its thin flowing edge, and becoming thick, stunted, and gibbous." In slight cases, no other appearance of inflammation occurs in the eye, the conjunctiva remaining free from redness. In the more acute instances, however, the sclerotica is usually of a rose-red colour, shading off gradually towards the circumference. The pain, in instances of this kind, is often fitful, and is particularly severe in the evening or early in the morning. The usual sensation, however, (except during these even- ing or morning exacerbations,) is a feeling of constant painful pressure in the globe of the eye, with more or less of an aching pain in the temples, bone of the cheek, and forehead. In some instances, the * [I frequently resort to the mode of applying the nitrate of silver to the external integuments, so as to blacken the cuticle over the lids, and around them in all irrita- ble and painful inflammations of the eyes. During the last three or four years the London surgeons have generally depended upon this mode of applying their popular remedy to the eyes, instead of using it as a collyrium.—Mc.] IRITIS. 425 pain in the eye is pulsatile, " marking every injection of the ophthal- mic artery." In very acute and violent cases of iritis, lymph is de- posited on the iris, appearing in small yellowish-red elevations on its surface; the pupil usually becoming angular and misshapen, and sometimes entirely blocked up by a layer of lymph. Mr. Travers divides iritis into primary and secondary. The primary variety is commonly the consequence of syphilis, or of cold while the system is under the influence of mercury, and is distin- guished from the secondary variety by " the more sparing vascu- larity of the conjunctiva, and the consequent more distinct appear- ance of the vascular corona round the cornea." It usually comes on rather suddenly ; is attended with very severe pain in the orbit and head almost as soon as it commences; and " the vision is more quickly and completely dimmed. In the secondary form the inflammation gradually extends from the contiguous tunics to the iris; the con- junctiva is vascular and often rose-red; the cornea much clouded; the pupil retains its natural shape, or is but slightly deformed; the pain is confined in a great measure to the eyeball, and is not often very severe, but the intolerance of light is generally very considera- ble." (Travers.) When the disease is violent, and continues unchecked in its course, the iris projects forwards, and uniting with the cornea, produces cor- neal staphyloma. If the inflammation extends to the choroid mem- brane, retina, and vitreous humour, vision will inevitably be lost. Strumous iritis is most apt to occur in children between the ages of six and eighteen, of a delicate habit, " fair complexion, light hair^ and blue eyes." The cornea acquires a misty or slightly opaque appearance, with patches of red vessels usually appearing on its edges. A zone of pink vessels is formed around the cornea in various situations. The conjunctiva is but slightly red ; and on close inspec- tion, the vessels of the sclerotica are found minutely injected, and run- ning in straight lines to the margin of the cornea. Profuse lachry- mation occurs, with distressing intolerance of light. The iris is nearly inactive, and vision is obscure. "The eyebrow appears to project considerably before the eye ; the muscles (if one eye only be affected), become thicker and stronger than those of the opposite side, from their powerful contraction to exclude the light, and give to the coun- tenance a distorted appearance. The pulse is generally quick and irritable; the appetite uncertain ; the secretions unhealthy; the skin dry and harsh, but variable in temperature ; the heat of the scalp being oppressively great, whilst the extremities are often chilled with cold." Treatment.—Although mercury may be regarded as the principal remedy in this variety of ophthalmic inflammation, yet, general and local depletory measures, free purgation with calomel and jalap, and nauseating doses of antitnonials, are essential auxiliaries in the acute stage of the disease. Without mercury, little or nothing can be effected towards arresting the progress of the inflammation. It should be given to the extent of producing ptyalism, except in subjects of a debilitated and worn-down constitution, where a more moderate 426 EXANTHEMATA. mercurial action should be established, and the system supported by a nourishing but unirritating diet. Great care must be had to avoid taking cold while under the mercurial influence in this affection. Belladonna is a highly important remedy in this species of ophthal- mia. Without the use of this narcotic, says Mr. Guthrie, "complete success can rarely be obtained." The extract must be thickly smeared on the eyelids and eyebrows every night. After the inflammation has been considerably reduced, and the intolerance of light removed, a very small portion of weak precipitate ointment introduced into the eyes twice a week, will often aid materially in completing the cure. Bleeding, cupping, leeching and blistering are all wholly ineffectual and not unfrequently decidedly injurious. (Guthrie.) Mr. Middle- more, assistant surgeon of the Birmingham Eye Infirmary, has pub- lished a statement which would seem to show that much advantage may be obtained from the use of the spirits of turpentine in this affection.* Mr. Carmichael and Mr. Guthrie have also given reports illustrative of the usefulness of this remedy. Mr. Middlemore asserts that he gave it with advantage to patients, who, from delicacy or constitutional idiosyncrasy, were unable to use mercury to the extent of producing salivation. Where the acute symptoms had been re- lieved by mercury, the turpentine given in drachm doses, two or three times daily, manifested a peculiarly excellent effect. He insists strongly on the early employment of this remedy in inflammation of choroid and retina. Strumous iritis is extremely obstinate in its duration. In delicate children, very small doses of calomel with prepared chalk may be given every evening, and a grain of quinine twice during the day. The quinine will often do more good in cases of this kind than any other remedy we possess. A seton in the nape of the neck, or a small issue on the arm, will in general contribute considerably to the reduction of the inflammation. Suitable clothing to keep up the regular warmth and action of the skin is an important auxiliary. The patient should also be allowed moderate exercise in the open air; and a simple digestible and nourishing diet is to be enjoined. CHAPTER XVII. OF THE CUTANEOUS PHLEGMASIA. Exanthemata. The term exanthemata is derived from the Greek word t%av9eu, effloresco; and is employed to designate those acute contagious affec- tions, in which an efflorescence or eruption appears on the surface of * Medico-Chirurg. Rev.. July, IS30. VARIOLA. 427 the body. The exanthematous fevers are of a strictly specific charac- ter:—that is, each affection of this kind has its specific cause, and cannot, so far as we know, be produced by any other cause or com- bination of causes. In all of them, fever exists as the primary or essential disease—the eruption being a secondary affection, and the immediate consequence of the specific febrile excitement. Unless interrupted by constitutional idiosyncrasy, or adventitious influences, each of these diseases has its determinate course, both in relation to the duration of its stages and the succession of its characteristic phenomena. They are all communicated by contagion; and they possess the power of destroying the susceptibility of the human organi- zations, to the subsequent morbific influence of their respective con- tagions, although instances do occasionally occur in which this power is more or less effectively opposed by the system, and in which, there- fore, a second attack is possible. Sect. I.— Variola.—Small-pox. It is not known at what period the small-pox made its first appear- ance. In the writings of the Greek and Roman physicians, we find nothing which could lead us to believe that they had any particular knowledge of this devastating malady .although we can scarcely doubt that its origin was of a much earlier date.* The Arabian physicians were the first who gave a distinct description of this disease; and it is to the small work of Rhazes, who lived about the beginning of the tenth century, that we must look for an account of its early history. It may be collected from the writings of Rhazes and others, that small- pox was probably at first brought from Ethiopia into Arabia, and that it was thence conveyed into the Levant, Spain, and Sicily, by the * Rhazes, indeed, refers to some expressions in the writings of Galen, which would seem to show that small-pox, though not described, was known by this Roman writer. " As to those physicians," says Rhazes, " who affirm that the most excellent Galen has made no mention of the small-pox, and therefore that he did not know this distemper, surely they have either never read his works at all, or only very cursordy; nay, most of them do not know whether what he plainly says of it is to be understood of that disease. For Galen, in a certain treatise, says: this *** does good against the small-pox. And in the beginning of the fourteenth book of pulses, he says, that the blood is putrefied in an extraordinary degree, and that the inflammation runs so high that it bums the skin; so that small-pox and pestilent carbuncle are bred by it. And in the ninth treatise of the book of the use of the Parts, he observes, that the superfluous parts of ailments which are not turned into blood, and remain in the members, putrefy, and in time increasing, do ferment: whence, at last, are generated the pestilential carbuncle, the small-pox, and confluent inflammations. Lastly, in the fourth part of his commentary upon the Timmus of Plato, he says, that the ancients gave the name of N rally urgent, and the heat of the skin more intense than in any other ") febrile affection. Currie and Willan have found the temperature of the surface as high as 108 and even 112 degrees of Fahrenheit's thermometer. The tongue soon becomes dry, and very florid along the edges, with the inflamed papillae projecting from its surface. Considerable uneasiness or pain is felt in the head, and much restless- ness, languor, and prostration prevail throughout the whole course of the disease. The eruption does not generally come out as early in this as in the simple variety. It usually makes its appearance on the third day of the fever, and is seldom diffused over the whole surface, com- ing out in irregular and not very large patches on different parts of " the body, particularly about the elbows. In some instances, the efflorescence disappears the day after it has come out, and " reap- pears partially at uncertain times, but without any corresponding changes in the general disorder; and the whole duration of the com- plaint is thus lengthened, and the desquamation is less regular." (Bateman.) When the fever declines as early as the fourth or fifth day, the tonsils and palate seldom become ulcerated, the swelling and inflam- mation in the fauces passing off with the fever and the eruption without ulceration; but, when the fever is protracted beyond this period, or when it is violent during the first three or four days, small ulcers form about these parts, which are rapidly converted into ash- is the most frequent cause of it; for if there be a latent weakness in any organ, the simple excitement, if not timely moderated, is sure to give rise to inflamma- tion there. It is on this account that many diseases merely marked by simple excitement at the beginning, are complicated with inflammation in their progress; and hence it is that apparently benign seizures of scarlatina may eventually become the causes and concomitants of serious affections of some of the viscera. It is, indeed, only in subjects of the soundest constitutions that we ever see simple excitement uncombinedly exist throughout the disease; and the reason why it so frequently occasions inflammation is, that some tissue or other had been secretly in fault before its occurrence.—On Measles, Scarlatina, fyc, p. 157. SCARLET FEVER. 469 coloured superficial sloughs. There is always a considerable quantity of viscid mucus secreted in the fauces, which often concretes into white flakes upon the inflamed parts, and presents the appearance of ulcers where in reality none exist. The parts should, therefore, be carefully examined before an opinion is expressed as to the exist- ence of ulcers. (Armstrong.) As the fever declines, the sloughs in the throat begin to separate, and leave red ulcerated surfaces, which generally cicatrize without difficulty. Sometimes, however, instead of separating about the eighth day, the sloughs enlarge, become brown, and discharge an acrid sanious fluid; and in such cases the glands about the neck are generally swollen, hard, and painful; and the patient is harassed with painful diarrhoea and tenesmus. The inflammation occasionally extends into the trachea, and the patient dies under symptoms of acute bronchitis. The brain, often becomes prominently aflected during the eruptive stage, giving rise to deep and fatal coma. Abdominal inflammations may likewise supervene. "At first there are only slight pain and soreness in some parts of the abdomen, with a quickened pulse and hurried respiration; but the pain and soreness gradually increase, and at length are attended with vomiting, eructation, fullness of the belly, and general restlessness. In six, seven, or eight days, the abdominal soreness and pain abate or disappear, while the pulse grows rapid and feeble, the breathing more anxious, and the vomiting more urgent. Cold clammy sweats, and an universal collapse, now speedily supervene, and are the immediate precursors of death." (Armstrong.) S. maligna.—Although this form of the disease usually commences like the preceding variety, it soon betrays its violent and dangerous character. The eruption comes out at uncertain periods from the second to the fourth day; and is usually pale when it first makes its appearance, acquiring, in most instances, a dark or livid hue in the progress of the disease. It is also very irregular in its duration, and often suddenly disappears soon after it has come out, and reappears on some parts of the body two or three days afterwards. The tem- perature of the skin is variable, and not generally very intense; and the pulse, though in the commencement active, becomes small and feeble in the course of the second day. Delirium generally occurs at an early period, and often continues with occasional intermissions and exacerbations, throughout the subsequent course of the disease. In nearly all cases the sensorial functions suffer very considerable disturbance ; and, in aggravated instances, the eyes are dull and in- flamed, and the cheeks suffused with a lived flush. The tongue is dry, and covered with a brown or dark fur; the breath fetid. On examin- ing the fauces, gray-coloured sloughs are seen on the soft palate and tonsils, which soon acquire a brown, and at last a dark colour. The disease, however, sometimes terminates fatally under symptoms of cerebral oppression, before the ulcers in the throat become extensive, or acquire a very bad appearance. " In general," says Dr. Armstrong, "it is only when the fever is protracted beyond the fourth day that the ulcers are converted into ill-conditioned, black, and fetid sloughs." There is generally a large quantity of very viscid mucus secreted and 470 SCARLET FEVER. lodged in the fauces, giving rise to difficulty of respiration and a rattling noise in the throat. "When the sloughs are foul and extensive,a thin acrid fluid is usually discharged from the nose, occasioning irritation and excoriation of the parts with which it comes in contact. In cases of a particularly violent character, collapse supervenes towards the middle or end of the second week of the disease. When this occurs, the heat of the surface sinks ; the pulse becomes very frequent and feeble, the tongue dark, brown, or black; the animal powers greatly prostrated ; painful diarrhoea often ensues, and in some instances petechia? and hemorrhages from various parts occur towards the fatal termination of the disease. The fever and ulcerous affection of the throat frequently exist without an eruption at any period of the disease. Death sometimes takes place as early as the second or third day, and Bateman observes, that occasionally the symptoms continue to be moderate until an advanced period, when they suddenly assume a malignant and rapidly fatal character. Dr. Armstrong has described three modifications of malignant scarlet fever—namely, the inflammatory, the congestive, and the mixed; the latter being attended, he says, at once with much internal congestion, and a moderate reaction of the heart and arteries. The first of these modifications (inflammatory) corresponds with the putrid variety of Richter.* It commences with violent fever; the pulse is full, strong, and hard ; the heat of the surface intense ; delirium occurs early; in short, all the symptoms indicate a high grade of in- flammatory excitement. The eruption conies out early, and is at first vividly red, assuming a darker or purple hue as the disease advances. In its commencement, and for a day or two,it resembles s. anginosa, differing from this variety in the early supervention of a typhous state or collapse, and in the affection of the throat assuming, in a few days, the gangrenous condition mentioned above. At an early period of the disease the animal powers sink; the pulse becomes small, feeble and frequent; the heat of the surface acrid and burning; the rash purplish; colliquative diarrhoea and hemorrhages, and occasionally petechias, or a miliary eruption, ensue. The most characteristic circumstance of this modification, however, is the extremely violent degree of the anginose affection, and its decided and early tendency to terminate in exten- sive gangrenous ulceration. It is this modification of the disease that was formerly commonly described under the name of putrid sore throat. In the congestive modification, the reaction does not ensue. The patient becomes pale, faint, and oppressed ; he complains of deep- seated pain and sense of weight in the head, attended with giddiness, nausea, much anxiety and oppression in the prascordia, and great muscular prostration. Respiration is quick, short, or slow and im- peded, " and there is often a mixture of lividity and paleness in the face, and the eyes are usually dull, acquiring a fatuous or inebriated expression in the course of the disease. The mind, at first alarmed and confused, or dejected, soon becomes disordered with delirium; or * Specielle Therapie, bd. ii, p. 466 SCARLET FEVER. 471 an indifference to surrounding objects, and a stupor succeed, under which patients frequently expire." The pulse is slow, irregular, and weak; at first the tongue is covered with a white fur, which becomes rough and brown in the progress of the disease. The bowels are torpid in the beginning, but towards the termination of the disease, diarrhoea almost always occurs in fatal cases. This modification of the complaint seldom runs a protracted course, and frequently proves fatal as early as the second, third, or fourth day. Colliquative he- morrhages from the nose mouth and bowels, petechias and gangrenous spots, are by no means uncommon towards the fatal conclusion of the disease. In this modification, the rash, from the commencement of its appearance, is pale or of a copperish hue, acquiring at last a purple aspect. The anginose affection is seldom very violent. Dr. Armstrong thinks that the affection of the throat is rarely the cause of death—its fatal tendency depending chiefly on the " venous congestions of the brain, liver, spleen, lungs, and of the vessels of the heart, giving rise to universal collapse and visceral disorganization," and perhaps to a change in the constitution of the blood itself. Sequelae.—Scarlatina, like measles, is frequently followed by vari- ous troublesome and often dangerous disorders ; amongst which, ana- sarca is by far the most common. There is, indeed, no acute disease which is so apt to be succeeded by dropsical effusions as scarlet fever; and this is especially the case with the anginose variety. These swellings seldom occur before the ninth or tenth day after the erup- tion has gone off, and continue usually two or three weeks. Bateman observes, that " when the anasarca becomes pretty general, a sudden effusion occasionally takes place into the cavity of the chest, or into the ventricles of the brain, occasioning the death of the patient in a few hours." In general, however, the dropsical effusions which occur after scarlatina, are not attended with much inconvenience or danger. The malignant and anginose varieties are sometimes followed by abscess of the tonsils, enlargement of the parotids, inflammation of the testicles, ophthalmia, deafness, and inflammation of the mucous mem- brane of the alimentary canal, otitis, suppuration of the glands about the neck, chronic cough, excoriations about the nates, and bronchitis, or other slow suppurative inflammations, with hectic fever and its consequences. It is observed by Dr. Armstrong and others, that the hair is very apt to come out on the abatement of scarlatina, and that it often never looks or grows well afterwards. Various nervous affections have also been known to occur as sequelas of this disease:— such as hysteria, spasmodic asthma, chorea, epilepsy,* and neuralgic pains in the extremities. Strumous affections, chronic cutaneous eruptions, gutta serena, herpes, and rheumatic pains, are occasionally the consequence of the disease. The more perfectly and obviously the cuticle desquamates, the less apt are secondary diseases to super- vene during convalescence. * Kreysig, Abhandlung uber das Scharlachfieber, &c, p. 99. See also Cappel. Abhand. von Scharlachsauschlage, p. 90. Reil, Fieberlehre, bd. 5, p. 122. 472 SCARLET FEVER. Diagnosis.—The only diseases with which scarlatina is liable to be confounded, are measles and miliary fever ; and in the simple and anginose varieties, the diagnosis is indeed sometimes attended with very considerable difficulty. There is not a single symptom which can be regarded as absolutely peculiar and characteristic of scarlet fever. The eruption is sometimes wholly or nearly absent, is diffused or in blotches, and occasionally papular ; and the angina varies from only a slight redness to much tumefaction, with or without ulceration and sloughing. Nevertheless, the following circumstances will almost always enable us to distinguish scarlatina from measles. In the former the eruption generally comes out within the first forty-eight hours of the fever ; whereas in measles the rash rarely appears until the third, and most commonly not until the fourth day. The eruption in scar- latina appears like a diffused erythematous blush of the skin, with innumerable points intermixed with small papulae, dispersed over the cuticle. The rash of measles, on the contrary, consists of small cir- cular dots, like flea-bites, of a deeper red in the centre than at the circumference, so that, in running into each other, the skin presents a less uniform blush than in scarlatina. These red and slightly elevated dots generally appear in clusters or patches, assuming an irregular crescent shape. " The crescent-like form of the patches of measles," says Bateman," and the more diffuse and irregular shape of those of scarlatina, will be a material diagnostic guide." The colour of the eruption of scarlatina usually resembles that of a boiled lobster shell. In measles it is generally of darker red, inclining slightly to brown. The most prominent diagnostic symptoms between these two affections, however, are the catarrhal phenomena, which are almost invariably very conspicuous in measles, whilst in scarlatina they are either altogether absent, or extremely slight and partial. The inflamed eyes, profuse discharge of tears, sneezing, coryza, strong, harsh, and hoarse cough, intolerance of light, and red and swollen edges of the eyelids, so seldom absent in measles, are but very rarely noticed in scarlet fever. In the malignant and anginose varieties of scarlatina, the ulceration and sloughs which appear in the fauces are sufficiently characteristic to distinguish this affection from measles. In some instances, simple scarlatina assumes so much the general appearance of miliary fever, that on slight examination it might be readily mistaken for this latter affection. They may be distinguished by the miliary eruption being almost universally attended with con- siderable perspiration, which is not the case on the appearance of the efflorescence of scarlatina. The little points or miliary papillas of the rash of scarlet fever, rise out of a uniformly erythematous blush of the skin, whereas those of miliary fever appear to be seated on a skin possessing its natural colour. The coming out of the miliary eruption is generally attended with great anxiety in the prascordia; and when it is about declining, a second eruption, similar to the first, sometimes comes out; and in some instances a third crop of papulas supervenes. Prognosis. — The prognosis in scarlatina must of course be ex- tremely various, since the disease assumes every grade from the SCARLET FEVER. 473 mildest to the most fatal degrees of violence. In the simple variety, little or nothing in general need be apprehended for the safety of the patient, unless dangerous secondary affections supervene during the declension or period of convalescence, from cold or other accidental causes. But the prognosis ought to be cautious, even in cases which appear at first under mild symptoms; for the disease will sometimes go on for a few days in a regular and simple form, and then, all at once, assume a highly dangerous grade of violence ; and this is more especially apt to be the case when the epidemic generally is of a severe character. The anginose variety of the disease can never be regarded as free from particular danger ; and the malignant variety is to be accounted among the most fatal maladies. It is generally, and perhaps justly, considered that the danger in scarlatina is to be estimated by the character and violence of the affection of the throat. Dr. Armstrong, however, seems to be of a different opinion: at least, the affection of the throat, abstractly considered, he thinks, is rarely the cause of death—a termination which he refers rather to violent internal venous congestions and visceral disorganizations, so common in the more violent grades of this disease. When the eruption is bright red, and uniformly diffused over the whole or the greater part of the body, the prognosis is better than when it is pale, or purple, or brownish, and appears only here and there in large patches. (Arm- strong, Reil.) A variable eruption, being by turns red, pale, and brown- ish ; appearing now principally in one part, and then in another; going off for a time, and again making its appearance, or finally sud- denly, and at an early period, vanishing entirely, are unfavourable indications. A white streak passing down on both sides of the nose and encircling it below, is said to be a fatal symptom. (Reil.) If on a sudden a strong inclination to pass urine occurs, and a copious flow of crude watery urine takes place, the danger may be considered great. (Richter.) When the inflamed fauces are of a bright red colour, con- siderably tumefied and attended with painful swallowing, the progno- sis is better than when the inflamed parts are dark-red or livid, and without swelling and difficult deglutition. White sloughs in the fauces are more favourable than ash-gray or brown ones. The occurrence of gangrenous ulceration is of course of very alarming import. It is scarcely necessary to say that the grade and character of the attending fever have an important bearing on the prognosis. A mode- rately active state of the reaction is favourable; a typhous grade is the reverse; and when the fever is extremly violent at first, with much angina, there is great reason to apprehend early and dangerous col- lapse. Violent internal venous congestion, by which the development of febrile reaction is prevented or much impeded, is always indicative of the utmost danger. The supervention of visceral inflammation is no less alarming. These are generally soon followed by collapse, and if death does not take place early, great prostration ensues, with the fatal symptoms of coma, constant delirium, cold extremities, and if to these are added petechias, colliquative hemorrhages, and involuntary evacuation of fasces, a speedy dissolution may be predicted with certainty. 474 SCARLET FEVER. In general, scarlatina is apt to be more mild in children than in adults, except when the former are suffering from painful dentition. The disease is said to be most dangerous when it occurs in persons between the ages of fifteen and twenty-five.* It is also attended with particular danger when it attacks pregnant women, and especially in the puerperal state. In general, robust and healthy individuals bear the disease much better than persons of a weak, lymphatic and ner- vous temperament. A regular abatement of the heat and efflorescence of the skin, ac- companied with a lateritious sediment in the urine; a subsidence of the swelling, and of the frequency of the pulse; with separation of the sloughs and healthy granulation of the ulcers; and finally, de- squamation of the cuticle, are indicative of a favourable termination of the disease. Cause.—Scarlatina arises from a specific contagious miasm or prin- ciple, which, like most other febrile contagions, appears to be much under the influence of certain occult atmospheric temperaments, as is manifest from its occasional epidemic prevalence, as well as from the various grades of viole/ice and diversity of character which dif- ferent epidemics have been known to assume. It agrees, moreover, with the contagion of small-pox and measles, in destroying the sus- ceptibility of the system to its subsequent morbific influence; although exceptions to this rule have been noticed, the disease having in some instances, though extremely rarely, occurred a second time in the same individual. There has been much controversy in relation to this latter point. Withering and Willan assert that they never wit- nessed a second attack of the disease, and they deny the possibility of this occurrence; and Bateman observes, " that this fact is now fully ascertained." Cases of second attacks have nevertheless been adduced by authorities equally respectable, and the reality of .this occurrence, though rare, appears to me sufficiently established. Bicker,! Neuman,J Binns, and others, mention instances of this kind; and Richter observes, that cases of a second, nay, even a third attack of scarlatina, have been noticed.§ Some individuals are wholly insusceptible to the operation of this contagion, and never become affected with the disease, however frequently they may be exposed to its cause. Accidental predisposition, age, and idiosyncrasy of con- stitution, have of course as great influence on the activity of this as of other contagions. The period which intervenes between the first impression of the contagion and the manifest commencement of the disease, varies from three to five or six days. It is asserted that the contagion emanating from an individual affected with the disease, is most active during the period of desquamation. (Cazenave.) Although unequivocally depending on a peculiar contagion, yet * Red, loc. cit., vol. v, p. 138. t Beschreibung eines Scharlachfiebers.—Rotterdam, in 1778 and 1779, p. 162. X Aufsatze and Beobachtungen fur Aertze, p. 284, as quoted by Red, loc. cit., t. v, p. 136. k Specielle Therapie, bd. ii, p. 440. SCARLET FEVER. 475 «there is abundant evidence that fever attended with scarlet erup- tion, and possessing all the other characters of this disease, does occa- sionally arise from exposure to cold."* Scarlatina occurs at all seasons, but it has been observed that warm and damp weather, and the air of low and marshy districts, have a tendency to promote the dissemination as well as the violence of the disease. It is also said, (Reil, Richter, Steiglitz,) that this disease is more apt to affect females than males; and general observation goes to show that nurslings and old persons are much less subject to the influence of its contagion than individuals during the intermediate ages. Some epidemics affect scarcely any but children; others seize almost exclusively on adolescence and adults. Reil says that he has seen malignant epidemic scarlatina which was almost entirely con- fined to persons between the ages of fifteen and twenty-five. The progress of epidemic scarlet fever is sometimes very irregular. The disease, though very violent and general, sometimes suddenly abates so as almost to disappear, and after a while resumes its power and rages with still greater malignity. Occasionally the contagion appears to linger for several years in a certain district, a few patients only becoming, from time to time, affected with the disease. Treatment.—From what has been said of the various symptoms and characters which scarlatina may present, it is at once obvious, that the remedial management of the disease must be greatly modi- fied in the different varieties which it is wont to assume. In the simple form of the disease, nothing but the mildest antiphlogistic treatment is necessary. One or two gentle aperients, or enemata; a mild, unirritating liquid diet; cool or tepid drinks, such as barley- water; toast-water, acidulated with lemon-juice, or muriatic acid, or lemonade; confinement in a moderate and equable temperature ; with the use of slightly astringent and emollient gargles—such as sage- tea, with a small portion of alum, and sweetened with honey; or an infusion of green tea, is all that is, in general, necessary to resort to in cases of this kind. But even the simple form of the disease occurs, occasionally, under symptoms of very considerable febrile irritation, and may, by the continuance of the high excitement, assume the severer character of scarlatina anginosa. No regard should, there- fore, be paid to the mere decision of its being a simple form of the disease; but where the general excitement runs high, it will be pru- dent to adopt a more active antiphlogistic treatment, and to regulate it in such a manner as to restrain the phlogistic tendency without interfering too much with the regular, and we may presume neces- sary excitement of the heart and arteries. Although it may be true, nay, most assuredly is true, that the " nimia diligentia medici" has done more harm in simple scarlatina than the disease itself, yet the intelligent and experienced practitioner has a safe and a sure guide in the grade of the existing symptoms, to direct him in the applica- tion of antiphlogistic measures. It is moreover to be observed, that in the onset of the disease, it is * Gregory's Elements of the Theory and Practice of Physic, vol. i, p. 244. 476 SCARLET FEVER. not always in our power to decide satisfactorily whether its subse- quent course will be simple or complicated, or severe and dangerous^ However mild, therefore, the general character of the prevailing epi-" demic may be, it will be proper, whenever we are called to a case during the forming stage, attended with considerable lassitude and oppression, paleness of the face and skin, some headache and nausea, to commence the treatment as if the disease were about assuming an aggravated character. An emetic will under such circumstances fre- quently do much good by removing internal venous congestions; and after its operation, a brisk mercurial purge may be given with advan- tage. In cases attended with considerable affection of the head during the forming stage, Dr. Armstrong advises the use of the warm bath strongly impregnated with salt. " This practice," he says, " assisted by a brisk purgative, will in general give immediate relief, and con- tribute powerfully to moderate the subsequent reaction. When the subsequent febrile excitement becomes strongly developed, it should be moderated by purgatives, tepid affusions, cooling drinks, rest, ventilation, and some of the milder diaphoretic remedies—such as spiritus mindereri, sweet spirits of nitre, or small doses of nitre and antimony."* In the anginose form of the disease, a much more energetic course of treatment is requisite. Almost all writers agree in recommending the use of emetics in the beginning of this, as well indeed as in the other varieties of scarlatina. The earlier they are resorted to, the more beneficial, in general, will be their effects; and it is particularly in the forming stage, or at the very onset of the febrile excitement, that they may be employed with decided usefulness.t When given at this early period, they frequently moderate the whole subsequent course of the disease, and in some instances almost completely break up the train of morbid actions. They have indeed been recommended throughout the whole course of the disease, (Withering,) but general experience goes to show that the commencement of the disease is _ihe only proper period for their employment. The good effects of an emetic, in the beginning of the disease, depend, probably, chiefly on the centrifugal direction which active vomiting communicates to the circulation, and thereby obviating internal congestions and se- condary inflammations; and perhaps, also, by weakening the morbid sympathies established by the cause of the disease. Purgatives have of late years been strongly recommended in this affection, and they are, without doubt, often highly useful, although * Armstrong. Treatise on Scarlatina, Measles, &c. t Numerous authorities, of great weight, might be quoted in'evidence of the good effects of emetics in this disease. They are recommended by Tissot, (Avis au Peuple;) StoU, (Ratio Medend., tom. ii, p. 248 ;) Withering, (Account of Scar- let Fever and Sore Throat, &c, as it appeared at Birmingham in 1773, and Lon- don in 1799, p. 300;) Steiglitz, (Versuch einer pruning und verbesserung der yezt gewohnlichen behandlungsart des scharlachfiebers, p. 241;) Richter, (Specielle Therapie, bd. ii, p. 480;) Reil, (Fieberlehre, tom. v, p. 166;) Armstrong, (on Scarlet Fever, &c.:) Rush, (Medical Inquiries.) SCARLET FEVER. 477 there formerly existed much prejudice against their employment. The utility of this class of remedies in scarlatina is particularly in- sisted on by Dr. Hamilton;* and all modern writers speak favourably of this practice. My own experience, though limited in this variety of the disease, has strongly impressed me with the utility of moderate purgation in this affection, and with the exception of an antimonial emetic in the commencement, I have in most instances confined my- self almost entirely to the employment of aperients, with cooling applications to the surface, an antiphlogistic regimen, and the local applications to be mentioned hereafter. The judicious employment of laxatives in the early periods of the disease, is the most effectual measure for preventing the occurrence of colliquative diarrhoea in the latter stage—an occurrence which is always attended with danger. It is by no means necessary, or as a general rule, even proper, to use active purges. From three to four evacuations in the course of twenty-four hours are sufficient to procure all the advantages which i' purgatives can afford,t unless cerebral congestion exists, when active catharsis will be very'proper.J With regard to the employment of antimonials and the usual dia- phoretic antiphlogistics, experience does not furnish us with any ; satisfactory evidence of their usefulness. "In truth," says Dr. Bate- man, "the temperature is too high to admit of a diaphoresis; and * the only safe and effectual method of producing this effect, consists in reducing the heat of the surface by the application of external cold.§ Richter, nevertheless, speaks favourably of the internal em- ployment of the muriate of ammonia, when the fever is strong, after the bowels have been regularly evacuated.|| It should be given in union with tart, antimon. in the way directed at page 127. If, not- withstanding the use of purgatives, and the other remedies already mentioned, the inflammatory condition increases, and the patient be- comes anxious and very restless, the use of diluted sulphuric acid, in large and frequent doses, is according to the experience of Steiglitz, a valuable remedy. (Abhandl. fur Pract. Arzte. b. xxii, p. 307.) The application of cold water to the surface of the body cannot be too strongly recommended in the higher grades of this affection. " We are * Treatise on Purgatives. t Bateman, Gregory, Richter, Reil, Willan. Dr. Armstrong, however, recom- mends active purges in preference to the milder articles of this class, in the angi- nose variety of the disease. X Rhubarb and calomel; rhubarb and soda in equal parts; calomel with small portions of antimonial powder, (Willan;) calomel, followed by a small dose of magnesia; small portions of the sulphate of soda or magnesia; an occasional dose of two or three grains of calomel, with the daily use of a dose of castor oil, or the administration of laxative enemata, may be used for this purpose. $ [Cool air and cold water are no doubt worth all the other remedies in scarla- tina. I always make it a rule to take my patients out of stove or funiace-heated apartments; and in the coldest weather, allow only a wood fire in a wide-throated ' chimney.—Mc] [| Specielle Therapie, b. ii, p. 490. 478 SCARLET FEVER. possessed of no physical agent," says Bateman, " as far as my expe- rience has taught me, (not excepting even the use of blood-letting in acute inflammation,) by which the functions of the animal economy are controlled with so much certainty, safety and promptitude as by the application of cold water to the skin, under the augmented heat of scarlatina and of some other fevers. This expedient combines in itself all the medicinal properties which are indicated in this state of disease, and which we should scarcely a priori expect it to possess, for it is not only the most effectual febrifuge (the < febrifugum mag- num,' as a reverend author—Dr. Hancoke-long ago called it, (but it is in fact the only sudorific or anodyne which will not disappoint the expectation of the practitioner under these circumstances. I have had the satisfaction, in numerous instances, of witnessing the imme- diate improvement of the symptoms, and the rapid change in the countenance of the patient, produced by washing the skin. Invaria- bly, in the course of a few minutes, the pulse has been diminished in frequency, the thirst abated, the tongue has become moist, a general free perspiration has broken forth, the skin has become soft and cool, and the eyes have brightened; and these indications of relief have been speedily followed by a calm refreshing sleep.* The only precaution * [ My learned friend, Dr. Samuel Jackson, formerly of Northumberland, but now a distinguished practitioner in this city, has kindly furnished me with the following note in relation to his experience with ice in scarlatina. Its excellence and practical utility will render it unnecessary to apologize for its length, and I will therefore print it entire. "In the autumn of 1832 and the following winter, the scarlatina, in form of cynanche maligna, ravaged the country north-west of Northumberland, and proved mortal to whole families. There was seldom any exanthema, the whole disease centering in the fauces and running quickly into mortification. What was the treatment, I never fully ascertained: but blisters were often applied to the throat, and not unfrequently they produced mortification. " In November, 1832, the disease, in its progress to the north-east, reached Lewis- burgh and Milton, 8 and 12 miles to the north-west of Northumberland, and brought terror and dismay into every famdy. My friend Dr. Vanvalzah, of Lewisburgh, sent for me to visit his son and other cases in the town. The disease appeared as a violent inflammation passing rapidly into sphacelus. A few were saved in the region of these towns by capsicum gargles and quinine as a general tonic, but the majority of cases were lost. " In the following spring the disease reached Northumberland, and the first patient was my own child, whose case T have recorded in the Amer. Journ. of Med. Sciences for May, 1833. Her fever was plainly of the typhous character, with a very rapid pulse, hot skin, distressed countenance, the fauces severely inflamed from the first, and without pain or difficulty of deglutition. I bled her to :| viii in the evening paroxysm, evacuated her stomach and bowels by tart. emet. and calomel; for a gargle, a solution of sac. sat. was used. On the second day the cineritious spots appeared, and hence the gargle of lead was changed for one of nit. argent. 24 grs. to water gi. She craved cold water very ardently, and this fact associated ke with the fiery inflammation of the fauces. She was desired to hold lumps of ice in her mouth as far back as possible and to swallow SCARLET FEVER. 479 that it is necessary to observe in the application of cold water to the surface in this and other febrile diseases, is to see that the skin is above the natural temperature, and dry, and that no feeling of chilliness be the solution; lest she might let the undissolved lump pass into the stomach, it was pounded and enclosed in a gauze bag. The good effects were immediate, sur- prising, incredible, and almost divine. Within two or three hours the pulse was reduced from 150 to 120; the circumscribed crimson disappeared from her cheeks; the extremities became warm in proportion as the feet and stomach were cooled; the whole aspect was changed from that of a typhous to that of acommon fever. No other remedy was used; the cineritious spots and fiery inflammation soon disap- peared under the continual use of ice, without any tonic local or general. " Many cases soon occurred in Northumberland and its vicinity which were all treated in the same way and with entire success. The people had been so alarmed by reports from the north-west, that they lost no time in applying where they had heard of such certain relief. Now was the danger merely a phantom. A robust boy, four years old, son of William Zeelif, died to the surprise of his friends, and without medical aid; I was then called to the rest of the family, four mdes in the country, where I found the mother, her sister, and three children, the youngest six months old, all very ill. Here was certainly a mortal disease, as it had already destroyed one of the family, but all the rest recovered under the use of ice and chloride of soda. Mrs. Schuyler, of Northumberland, lost one of her children of the disease, at Muncy, 27 miles north of Northumberland. Here neither ice nor chloiide was used; but when she returned home, her other three children were severely attacked, and they all recovered under the use of ice, without any other application to the throat. About the same time, Daniel Gossler lost two children, under the care of a hospital physician; the others recovered under the new re- medy administered by me. "So well known had I become in the treatment of this disease, that Mr. Hard- man Philips, of Phillipsburg, 96 miles from Northumberland, losing his two little sons by cynanche maligna, sent his only remaining child to my house that he might have the disease under my care. She arrived in her father's carriage by forced journeys in about twenty-four hours, while her parents remained to bury her brother. In two days she took the disease in my house and happily recovered. ((The following year I wrote Dr. Hays a letter, detailing my further experience. This was published in No. 24 of the Amer. Journ. of Med. Sciences for August, 1833, and from it I will copy a few observations. l I had now used the ice in more than forty cases of severe cynanche maligna, and found it highly useful; nay, I am almost certain that without it, more than half the number would have been lost. Drs. Magill, of Danville—Boskins, of Selinsgrove—and Lotz, of New Berlin, have all used it with the happiest effects, and these are truly respectable men both in morals and medicine. So necessary had the remedy become in the hands of Dr. Lotz, that Mr. Laschelles, a benevolent gentleman of New Berlin, refused the use of his ice even to his own family, reserving it all for the sick; and Dr. Lotz frequently carried it with him in his visits to the country. The patient ought to hold the ice almost constantly in his mouth and swallow the solution; and if he be not old enough to rest on his guard against swallowing the undis- solved lump, it must be enclosed in a gauze bag. If the fever be very high, he may swallow small portions of it finely powdered. If he be too young to man- 480 SCARLET FEVER. present. When the arterial excitement is vehement, and the tem- perature of the surface intense, the water should be applied by pour- ing or dashing it over the body; but where this mode of using it is impracticable, or objected to on the part of the patient or his friends, we may obtain our object by washing or sponging the skin with cold water, or vinegar and water, and this should be repeated every hour or two, until the desired reduction of the heat and arterial excite- age ice, we inject the solution of it into his throat, and give him the powdered ice to swallow. The patient and the nurses can have very little rest unless it be a mild case that may not require uninterrupted repression and sedation; for they must not lose during the night what they have gained during the preceding day. If the inflammation is rather lively, the gangrene small, and there is yet abundant vivacity in the system, no other local remedy is needed. The sloughs will gradu- ally and surprisingly disappear as the general inflammation of the fauces abates. When the gangrenous tendency begins to predominate, we have found the chlo- ride of soda a noble remedy. In those cases attended with debility, whether with or without much gangrene, ice cannot be used, and our dependence has been on chloride of soda and capsicum alternately used. " < Every case of cynanche tonsillaris, or simple inflammatory sore throat, which has faUen under our care the last twelve months, has been treated with ice after bleeding, and with great advantage; and in one case of severe aphthous sore throat, that of Dr. Robbins, of Sunbury, he assured me it was the most comfort- ing thing he had ever experienced. " < During the subsequent five years that I practised in Northumberland, the dis- ease prevailed, but now there was the regular exanthema, and the throat was less violently affected. Still the ice was often necessary, and many who are now alive would have perished under any other known remedies. " ' In the forty-third No. of the Amer. Journ. of Med. Sciences for May, 1838, when I had removed to Philadelphia, I published my further experience, and gave the testimony of Drs. Magill, Lotz, Rodrigue, and my pupil Mr. Pleasants, now physician in West Philadelphia. Rodrigue says, c my chief dependence was on ice or iced water.' Dr. Lotz says, ' It is my decided conviction that ice is the most useful arti- cle in the whole catalogue of remedies. Not unfrequently, I wrapped large pieces in flan- nel and tied them to my saddle for the use of my country patients.' Dr. Magill says, (in the early stage, it has certainly effected more in my hands than all other remedies.' Dr. Pleasants, in his thesis, says, (Here, luckily for the inhabitants (of Northumberland,) the career of their enemy was arrested—here was it to encounter a powerful, a successful opponent.' " But to conclude, let us assure the reader that we are not proposing exclusive and infallible remedies in the manner of quacks. A distinguished physician of this city said to me, ' our patients will die notwithstanding your ice.' True, there are many advanced cases that no remedy will ever control; there wdl always be found some cases so vehement in the onset, that congestions with convulsions will quickly supervene; and there will often occur some patients so young and so unmanageable, as to frustrate continually our most resolute efforts. " As to the use of old remedies, I would gladly say many things, but this note is already too long; and I would beg to refer the reader to what I have said in the Amer. Journ. of Med. Sciences, vol. 22."—Mc] SCARLET FEVER. 481 ment is effected. Dr. Armstrong observes, that as the disease ad- vances, instead of cold, tepid affusions are to be used; and, as a general rule, he thinks it most prudent to resort to the latter after the third day of the stage of excitement. In this, however, we must be governed by the degree of arterial excitement, and of the heat of the surface present; for cold water may be safely and beneficially applied at any period of the disease, provided the skin be very hot and dry.* (Dr. Stranger.) Pmgatives.and,cold affusions may be employed con- jointly. Armstrong, indeed, asserts that when thus used they do more good than when employed separately, more especially during the first three days'df the stage of excitement; and several instances have come under my own observation which strongly favour this opinion. Blisters may sometimes be beneficially used during the first two or three days of the stage of excitement. When the tonsils are much inflamed and swollen, so as to render swallowing difficult, the appli- cation of a blister to the throat will often afford considerable relief. This practice is particularly recommended by Willan, Heberden, and Rush. When the disease is complicated with visceral inflammation, little or no relief will be obtained from the application either of cold or tepid water to the surface; and Armstrong observes, that where these measures, in conjunction with purgatives, do not afford any advantage, the practitioner may be sure that there is some latent in- flammation present. When this is the case, and collapse is not ap- proaching, recourse must be had to sinapisms, blisters, small general or topical abstractions of blood. Should there be manifestations of much vascular irritation, or of incipient inflammation of the brain— that is, should the face become flushed and turgid, with severe pul- sating pain in the head, more or less delirium, intolerance of light, and a disposition to somnolency, the patient must be kept in a cool situation with his head elevated, and blood drawn according to the state of the pulse J an active purgative administered, warm fomenta- tions, or sinapisms applied to the feet, and cold water to the head, and cups applied to the temples, or blisters to the back of the neck, provided always that collapse is not at hand. Unfortunately, how- ever, the supervention of internal visceral inflammations in this affec- tion is almost always speedily followed by collapse ; and in this state sanguineous and other evacuations are entirely out of the question.. Dr. Armstrong observes, " that in such examples the question is simply this—whether there is greater danger to be apprehended from the inflammation or from the depletion ?" Visceral inflammation, he says, almost invariably terminates fatally, but depletion produces debility only, and debility is rarely the cause of death. He is, there- * Willan on Cutaneous Diseases—note at p. 360. f Armstrong; Marcus, (Specielle Therapie, tom. iii, p. 272;) Lorry, (Hist, de la Soc. Roy. de Med., t. ii;) P. Frank, (de Curand. Homin. Morbis;) Rush, Bur- serius, (Institut. Med. Pract, vol. ii, p. 72;) Heim, (Horn's Archiv. fur Medic. Erfahr., vol. iv, h. 1, p. 150.) Richter and other eminent authorities may be adduced in favour of prompt blood-letting in such cases. VOL. I.—31 482 SCARLET FEVER. fore of opinion that an attempt ought to be made to arrest the inflam- mation by depletion, even in the stage of collapse, wherever it may be seated. It is true, that debility is perhaps rarely the cause of death; but it may be asked, why is visceral inflammation so fatal in such cases? The answer would seem to be :—because it is connected with universal debility; and the clear inference is, that whatever tends to augment this debility or prostration, must tend also to hasten its fatal termination. Before we adopt so desperate a practice, we should reflect that a small bleeding cannot materially influence or reduce the internal inflammation, and a large one must inevitably pre- cipitate the patient into fatal prostration. Such cases are indeed ex- ceedingly perplexing, for the remedies which are best and almost alone calculated to remove the inflammation, are also the most certain to increase the prostration. When the brain is the seat of the inflam- mation, we may apply fomentations to the feet, dry cups to the temples and shaven scalp, and exhibit active purgatives conjointly with carbonate of ammonia or camphor. In other visceral inflam- mations attended with collapse, I should be disposed to resort to calomel and opium, with dry cupping and large fomenting cata- plasms over the region of the affected part. Blisters in such cases are almost as hazardous as bleeding. They produce much general irritation, and the blistered part often becomes gangrenous. Malignant scarlatina, though generally strongly phlogistic in its commencement, passes so rapidly into a low and typhous state, that formerly physicians placed almost their entire dependence in its treatment on the active and early employment of bark, wine, and other stimulating and tonic remedies. "These remedies," says Armstrong, " so forcibly, so indiscriminately, and so fatally recom- mended by numerous authors, were once the means upon which, unfortunately, I relied for the cure of this modification of scarlet fever; and from repeated trials of them, I can truly affirm that they are the most pernicious in the first stage, and the most destructive in the second." However rapidly this form of the disease may pass into a low and malignant state, its onset is often characterized by highly inflammatory symptoms. The attack is vehement, and the febrile excitement at first tumultuous, tending rapidly to consume the vital energies; and in proportion to the violence of this excited, though transient stage, will be the tendency of the disease to assume a putrid character. It is therefore of the utmost importance to break down promptly, by energetic measures, the initial febrile commotion. I have already stated that the exhibition of an emetic, followed by a brisk purgative, in the chilly or forming stage, is often as beneficial in this as in the other modifications of the disease; and the treat- ment should always commence with these remedies, if we are called at a sufficiently early period. If, after the operation of these evacu- ants, the stage of excitement begins with violent symptoms—such as intense heat of the skin: severe headache; delirium; and a frequent, quick, and tense pulse; blood should be promptly and efficiently abstracted. (Burserius, Lorry, Armstrong.) As this stage is gene- rally but short, it is of great importance to draw blood at once in its SCARLET FEVER. 483 onset, to the extent of producing a very decided impression on the system; or, as Armstrong advises, until syncope approaches. By one such bleeding, and the brisk operation of a purgative, the vio- lence of the disease is often broken down, and its subsequent course rendered milder and more manageable. It must not be forgotten, however, that these active depletory measures must be entirely re- stricted to the early period of the stage of excitement; for when collapse is approaching, bleeding is wholly out of the question. (Armstrong.) Purgatives are always proper during the stage of excitement in every variety of scarlatina. Calomel has been parti- cularly recommended for this purpose both in the mild and the ma- lignant forms of the disease.* Dr. Rush gave this article throughout the whole course of the disease. Seeligt speaks in high terms of a combination of calomel, precipitated sulphuret of antimony, and tart, antimony, according to the formula below,J a combination which is said to be particularly useful as a gentle laxative, and antiphlo- gistic alterative in the present variety of the disease. In conjunction with purgatives we may use the ivarm bath with a prospect of ad- vantage, more especially in cases attended with internal inflammation. When a prompt and energetic antiphlogistic treatment is employed in the onset of the inflammatory form of malignant scarlatina, the system seldom sinks into a very low state of collapse ; and when this stage supervenes, after such a treatment in the commencement of the disease, we may, in general, give sufficient support to the vital powers by wine-whey, weak solutions of ammonia, infusion of serpentaria, a milk diet, quietness, and proper ventilation. (Armstrong.) When, from an inefficient or improper treatment in the beginning, or from a peculiar violence of the disease, great and universal collapse ensues, (which is indeed but too frequently the result, both in the inflammatory and congestive modifications of malignant scarlatina,) recourse must be had to a more active stimulating and tonic treatment. The carbo- nate of ammonia in frequent and active doses ;§ wine, camphor and * "It is somewhat remarkable," says Armstrong, " that calomel, though given! in large and frequent doses, wdl hardly ever produce ptyalism in scarlatina."' ... *-. He 6tates that he has frequently given from six to eight grains of this article to )* children, twice, thrice, and even four times daily, without having, in a single ;. instance, known it to produce salivation. He considers it the best purgative in every modification of this disease. t Hufeland's Journal, bd. 16, 1 st. Red's Fieberlehre, vol. v, p. 177. X R.—Calomel 7)i. Sulphuret. antimon. praecipit. gr. ii. Tart, antimon. gr. i.—M. Divide into twenty equal parts. Dose—one part to be taken every three or four hours by adults. \ Peart asserts that he has been so successful with the use of carbonate of ammonia, that out of three hundred cases in which he employed it, he lost but three patients. This, however, may well be deemed, ultra rem tendere, in com- mendation of this remedy; although, unquestionably, a highly useful medicine in the stage of collapse, not only of this but of all forms of disease.—Practical Irtformation on the Malignant Scarlet Fever, &c. By E. Peart, London, 1802. 484 SCARLET FEVER. opium where the brain is not particularly affected; infusion of ser- pentaria, with strong doses of elixir of vitriol, quinine and capsicum, are the remedies upon which our dependence must be placed. The capsicum appears to be a particularly valuable exciting remedy in this variety of the disease. This article was first employed in malignant scarlatina by Dr. Stephens,* in a very fatal epidemic which prevailed at St. Christopher's (West Indies) in'1787, and it has since received the decided approbation of many eminent practitioners t The man- ner of employing it is as follows: take two tablespoonfuls of small red pepper, or three teaspoonfuls of common Cayenne pepper, and two teaspoonfuls of fine salt; beat them into a paste, and pour upon them half a pint of boiling water; this is to be strained, and half a pint of good vinegar added to it. Of this liquor, when cold, a table- spoonful is to be taken every half hour by an adult, and the throat should be frequently gargled with it. Stephens asserts that he em- ployed this remedy in about four hundred cases, and with surprising success. The ulcers in the fauces soon cast off their sloughs and commenced to heal, a general pleasant warmth was diffused through- out the system, and the vital powers speedily resumed a more active condition. MalfattiJ speaks very favourably of the flowers of arnica; and Stieglitz employed them with much advantage in the sinking stage of the complaint. Reil strongly recommends large doses of musk, particularly where much restlessness and nervous irritation exist. Stimulating frictions with brandy, camphorated spirits, or tincture of capsicum, have also been found useful in the collapse of this disease. (Reil, Stieglitz.) In the stage of excitement, cooling drinks acidu- lated with lemon-juice, or the sulphuric or muriatic acids, should be freely allowed; but during the subsequent stages, infusions of sage, balm, or catnep, with sulphuric acid, are more appropriate. In rela- tion to the congestive modification of the disease, it is not necessary to say much in this place, for the principles of treatment are always the same in all congestive states of febrile diseases, and what has already been said of the treatment of congestive typhus, applies in all respects to the present malady when it assumes this modification. When the disease commences and proceeds under symptoms of oppressive in- ternal venous congestions, our first efforts must be to recall the circu- lation to the surface, and to relieve the internal organs; and for this purpose, our reliance must be placed on the assiduous use of frictions, and warm and stimulating applications to the surface; large doses of calomel, (20 grains;) stimulating enemata ; warm and gently stimu- lating ptisans, and small doses of camphor where the stomach is irritable. Having elicited a moderate degree of febrile reaction by these means, it will in general be most prudent to commence at once with the use of some of the milder stimulating remedies, such as infusions of serpentaria, calamus, wine-whey, or small doses of the * Edinburgh Medical Commentaries, Dec. 2, vol. ii, p. 75. t Cappel, loc. cit., p. 276, Kreisig, loc. cit., p. 113, and Seibert, Archiv. fur die Volksarzneikunde, p. 129.—As quoted by Red, loc. cit., vol. v, p. 175. X Hufeland's Journal, bd. 12, st. 120. SCARLET FEVER. 485 carbonate of ammonia; and as the disease advances and the signs of prostration increase, the more active exciting remedies already men- tioned must be employed, with an energy corresponding to the degree of prostration present. Local treatment.—Various local applications have been recom- mended for the purpose of moderating the tendency to ulceration in the fauces, or of checking the progress of the ulcers, favouring the separation of the sloughs, and disposing them to heal. Willan strongly recommends fumigation with nitrous gas; others speak favourably of the application of a weak solution of nitrate of silver* to the sores; and some recommend the sulphate of copper—all of which may, no doubt, be used with benefit. Various gargles also have been employed, and of these the infusion of Cayenne pepper, mentioned above, is perhaps the best. I have seen much good done in putrid sore throat by a strong infusion of the root of baptisia tinctoria, (indigo plant,) and I have also employed the black wash, (calomel gr. xx, lime-water Iviii,) with excellent effect in several cases of this kind. Barley-water, acidulated with sulphuric or muri- atic acid, forms an excellent gargle for washing off the acrid matter from the inflamed and ulcerated fauces. Dr. Barth has employed the pyroligneous acid for this purpose with signal advantage. He uses half an ounce of the acid with five ounces of water and an ounce of syrup; with which the throat is to be gargled every half hour.t Where there is no visceral inflammation, or collapse has not supervened in the anginose variety, a gentle emetic will often have an excellent effect in cleansing the sores and clearing the fauces from viscid and offensive matter. " Emetics," says Armstrong, " are the best gargles, where the throat is much obstructed from an accumu- lation of tenacious mucus; their operation effectually dislodges that morbid secretion for a time; often greatly relieves the respiration; improves the appearance of the ulcers; and they may be repeated where no abdominal inflammation exists, at any time during the continuance of the fever, whenever the respiration and deglutition become much impeded by an accumulation of phlegm." During convalescence from scarlatina, which is generally very tedious, a light and nourishing diet should be enjoined, and the patient carefully guarded against the influence of cold and variable weather. When there are considerable debility and relaxation present, mild tonic and cordial remedies should be prescribed, such as weak infusions of serpentaria, coloinba, gentian, or calamus aromaticus, with some of the mineral acids, particularly the sulphuric. In some cases, more or less general irritation remains during the early part of this period. The pulse is quick and frequent, the skin pale and dry, the bowels inactive, the appetite weak, and the sleep disturbed. Here tonics and cordials are entirely out of place. Recourse must be had to * [I generally apply the solid lunar caustic over the surface of 4he tonsils so as to coagulate the mucus every day in all severe cases of malignant scarlatina.__■ Mc] t Rust's Magazine, vol. xxvii, No. 1, 1828. 486 SCARLET FEVER. mild aperients, diaphoretics, warm bathing, and a simple and unirri- tating diet. Small doses of calomel in union with ipecacuanha, (one grain of the former to two of the latter,) three or four times daily; the muriate of ammonia; digitalis with the nitrate of potash; spiritus mindereri with minute portions of tartar emetic; infusion of eupa- torium perfoliatum, or of elder blossoms; acidulated diluents, &c, will generally answer well in cases of this kind. In all instances, the patient should be particularly careful to avoid taking cold; and as the susceptibility to the injurious effects of low and variable temperature is always especially great immediately after an attack of this disease, he should remain within doors during the whole period of convalescence, unless the weather be mild or warm. I have already mentioned dropsy as a very common consequence of every modification of scarlatina. This tendency to anasarcous effusion is generally ascribed to improper treatment during the febrile stage of the disease, or to errors in diet, or imprudent exposure to cold during the periods of desquamation or convalescence. That these causes have a particular influence in this respect cannot be doubted; but as dropsy sometimes occurs after the most judicious and careful management in all these respects, it would seem that the original disease itself tends ultimately to effusions of this kind, perhaps from not having passed regularly and completely through its specific train of morbid actions—the dropsy or some other disorder appearing afterwards as a complemental affection.* These dropsical affections are seldom either obstinate in their course or dangerous. In most instances of dropsy from this cause, the general state of the system is manifestly phlogistic. The pulse is quick, sharp, tense, frequent, and sometimes full; the skin dry, harsh, and preternaturally warm; the urine small in quantity, high-coloured, and charged with coagula- ble serum; and the bowels generally torpid. Here an antiphlogistic treatment is evidently indicated. Richter strongly recommends blood- letting, and other eminent writers (and amongst these several recent ones,) insist with equal emphasis on the propriety of this measure. Burserius gives an account of an epidemic scarlatina which prevailed at Florence in 1717. The disease yielded readily under the plan of treatment recommended by Sydenham. After the twentieth day from the commencement of convalescence, many became affected with a sense of weight in the chest, cough, oedema of the face and on the forepart of the neck. Fever soon followed; the dropsical effu- sion increased until it became general; the breast felt sore; the abdomen distended and painful; the urine very small in quantity, and in some instances almost entirely suppressed. All who took diuretics died. On dissection, the lungs, kidneys and intestines were found inflamed. Blood-letting was now freely resorted to in the cases which occurred, and the result was uniformly favourable.! Gregory seems to hesitate concerning the propriety of venesection in hydropic affections after scarlatina. He states that he has " met with * Red, loc. cit., vol. v, p. 186. f Burserius, Institutions Med. Pract., vol. ii, p. 81. SCARLET FEVER. 487 several cases which appeared to indicate bleeding and purging, but which resisted both, and ultimately yielded to bark and aromatic confection." My own experience leads me to place confidence in this measure, where the diathesis is evidently inflammatory; not, indeed, as a sole or even a principal curative means, but as an import- ant preparatory step to the employment of diuretics, purgatives and diaphoretics. The best diuretic in cases of this kind is digitalis, either alone or in union with small portions of calomel and nitrate of potash. As a purgative and diuretic, I have derived much advantage in this and other varieties of phlogistic dropsy from the following combina- tion.* Small doses of tart, antimon., dissolved in a large portion of some mucilaginous diluent, may also be used with advantage. Richter recommends large doses of calomel, from five to ten grains daily to children. The occasional use of the tepid bath will often prove beneficial, and the mildest farinaceous diet, with cooling acidu- lated drinks, and quietude, should be enjoined. Sometimes these dropsical effusions are entirely without any febrile irritation, the sys- tem being relaxed, torpid, and leucophlegmatic ;—the hydrops fri- gidus of the German writers (Reil). According to Richter, " the principal remedy, in cases of this kind, is calomel in doses sufficiently large to evacuate the bowels freely."t The cinchona bark, and the various medicinal preparations of iron, particularly the black sul- phuret, are often decidedly beneficial in this form of the disease. Among the diuretics, squill, spirits of turpentine,:]: and the tincture of cantharidis, have been especially recommended. (Hufeland, Bucholz.) The following mixture is said to have done much good in such cases.§ Prophylactic measures.—In Germany, and in France, many state- ments have been published which would seem to prove that the belladonna, when regularly taken by those who are exposed to the contagion of the disease, will effectually protect them from the infec- * R.—Crem. tart. %i. P. Sulphat. potassae giii. P. scdlae 3d. Tart, antimon. gr. iss.—M. S. Give from twenty to thirty grains four or five times daily to an adult. t Kreisig speaks equally favourably of calomel in this and other morbid con- sequences of scarlet fever. " Against the sequela? of scarlatina," he says, " the powers of calomel are great, and cannot be too highly praised."—Abhandl. vber das Sharlachsfieber, &c., p. 107. X R-—Spir. terebinth. §i. Tinct. opii. gtt. 1.—M. S. From ten to twenty drops may be given threa times daily to children from five to ten years old. k R.—P. cinchon. ^ss. Ap. fervent. §xii. coque ad reman. §vi. dein adde, Rad. polygal. sen eg. 3d. Fol. digitalis pi. cola, dein adde, Spir. nitri. dulc. 3d. Syrup, cort. aurant. gss.—M. S. Take from a tea to a tablespoonful every two hours, according to the age of the patient. 4SS ERYSIPELAS. tion. Hannemann, the author of the homoeopathic doctrine, first introduced this narcotic as a preventive of scarlatina, and in conform- ity to his views, he prescribes it in what may be called infinitesimal doses. He gives but forty drops in seventy-two hours, of a solution of which one drop contains no more than the twenty-millionth part of a grain of the extract I However incredulous we may be in rela- tion To the efficacy of such doses, we are not without respectable authorities in favour of the prophylactic powers of this article when given in small doses.* Bemdt asserts, that he gave it with unequivo- cal advantage in this respect. Dr. Koreff, of Berlin, found it to protect persons completely against this disease, when taken for eight or ten days before they were exposed to its contagion. Three grains of the extract are to be dissolved in an ounce of cinnamon water, and given in doses of from two to three drops to children under one year old, and one drop more for every year above this age.t Seclusion of the sick, free ventilation, frequent changes of the linen, aud other similar precautions, have been found completely effectual in preventing the communication of the disease to other members of the family. It does not appear that the contagious miasm of this disease is capable of attaching itself to clothes like some of the other exanthematous contagions. The breath of patients in the malignant form of the disease is said to be powerfully infectious; and the same has been observed with regard to matter discharged from the fauces. Sect. VI.—Erysipelas.—St. Anthony's Fire. Erysipelas is a febrile disease, attended with diffusive cutaneous inflammation on some part of the body, characterized by redness, burning heat, swelling, and vesication. In the majority of instances, various symptoms of deranged health precede the appearance of the erysipelatous inflammation—such as lassitude ; slight headache; loss of appetite; nausea ; general depres- sion; furred tongue; and a disagreeable feeling of weight in the epi- * [After a few apparently successful trials. Dr. Eberle was once induced to bedeve in the prophylactic virtues of the belladonna in this disease. But a con- tinuance of his experiments soon convinced him of the utter insignificance of the remedy, and long before he left this city for Cincinnati, he dismissed all confidence in this, his sole concession to the claims of homoeopathy. A brother practitioner. in the city of New York, had boasted before him that he never faded in deriving complete protection from the beUadonna; and also that he had always been able to cure every case of scarlatina, when developed in coiise mence of non-protection, by the same remedy. In a short time, however, we learned from the public prints. that the same physician had lost his three only children by the epidemic scarlatina of that year,in the course of three or four successive days. Notwithstanding these acts. I owe it in justice to the homcropathic gentlemen, to say that there are seve- ral respectable medical men in this country who s;dl have confidence in the curative as well as prophylactic powers of the remedy.—Mc] t Ed. Med. and Surg. Journ., Jan.. 1S25. ERYSIPELAS. 489 gastrium. These symptoms usually terminate in febrile reaction be- fore the cutaneous inflammation commences ; but in some instances the local and general affections come on simultaneously ; and occa- sionally the inflammation appears before the febrile irritation is de- veloped. Sydenham speaks of an erysipelas, in which the affection of the face preceded the fever. The inflammation comes out in the form of an irregularly circum- scribed stain or blotch, which soon spreads over a greater or less extent of the contiguous surface. When the inflammation is very superficial, the redness of the skin disappears, for a moment, on pressure being made with the point of the finger; but where the inflammation extends deeper, no white spot is left after pressure. Considerable burning and stinging pain, but neither pulsation nor tension, is felt in the inflamed part. Some degree of tumefaction always attends from the beginning, and increases, often to a very considerable extent, in the progress of the disease. After the inflam- mation has continued for an uncertain time, though usually about the third day, small vesicles, or blisters of various sizes, filled with a limpid or yellowish serum, make their appearance. On the suc- ceeding day, and sometimes not until two or three days after, these vesicles break, and discharge a viscid fluid, which occasionally forms crusts or large scabs. When the inflammation is about terminating in resolution, which usually occurs between the fourth and sixth days, the redness of the affected part diminishes, and assumes a pale or brownish-yellow colour; the swelling also begins to subside; the skin acquires a rough and rugose appearance; and, on the following day, desquamation takes place. The general or febrile symptoms commonly follow the progress of the local erysipelatous affection, both increasing and declining together ; yet, in their respective grades of violence, there is often no direct proportion between them; the fever being sometimes severe, with but a moderate local inflamma- tion, and vice versa. In some instances, the inflammation gradually travels along the skin, without increasing much in the extent of its surface, disappear- ing from the parts first affected, in proportion as it encroaches on the adjoining sound skin. La Motte gives the history of a case which commenced on the scalp, and in the course of three weeks, gradually traveled over the whole surface of the body.* Similar cases are related by other observers.t (Reil.) Occasionally, whilst it retains possession of the part first seized, it spreads more and more, until a large extent of skin, and in some rare instances, the whole surface of the body, is erysipelatous. Salmuth (cent, i, obser. 3)^ relates a case of universal erysipelas. Sometimes the inflammation disappears from its original seat, and comes out on some other, and often remote part of the body. Such are the general phenomena of erysipelas. It is subject, how- ever, to several prominent modifications, exhibiting important pecu- * Chirurg. t. i, observ., p. 92. t Ephem. Nat. Curios., dec. ii, ann. iii, ob. p. 171. 490 ERYSIPELAS. liarities both in relation to the character of the local affection, and the nature of the attending fever. The true seat of erysipelatous inflammation appears to be in the cutis, or the dermoid system generally ; and in its simple and regu- lar form, it is, in a great measure, if not wholly, confined to this structure. When the inflammation is very active, and extends itself to the subcutaneous and intermuscular cellular structure, it assumes somewhat of the character of common phlegmonous inflammation, constituting the erysipelas phlegmonodes of authors. This state of the disease is characterized by a decidedly synochal grade of fever; the pulse being hard, tense, and frequent; a vividly red appearance, and an extremely distressing burning heat and prickling pain of the inflamed part; a dry tongue, with urgent thirst; and a tendency to profuse sweats. The swelling usually commences about the second day of the fever; and in a few days more, small vesicles appear on the inflamed skin. When the disease tends to resolution, these vesicles break or subside about the fifth or sixth day; the redness assumes a yellowish hue; the tumefaction and fever gradually decline, and by the eighth day, the old cuticle begins to desquamate. Frequently, however, instead of taking a turn to resolution, the pain becomes throbbing, at the same time that the redness diminishes, and more or less extensive suppuration of the ordinary phlegmonous character takes place. Sometimes the inflammation extends deeply into the cellular tissue, and appears to commence simultaneously with the external or der- moid affection. In cases of this kind, the pain is always extremely severe; the skin tense, and exceedingly painful on the slightest pres- sure ; and the general phlogistic irritation vehement. " The termi- nation, except from energetic treatment, is seldom in resolution ; the suppuration, which takes place from the fifth to the seventh day, though sometimes sooner, is accompanied with irregular chills; the redness of the skin and the pain diminish, but the swelling increases; there is much doughiness, and the part remains in that state for some time. In some cases, the pus remains for a long time before an opening is formed in the skin to give it vent, but in general it escapes either by a natural or artificial orifice, mingled with shreds of gan- grenous cellular tissue. In these cases the course of the disease is ordinarily tedious ; sinuses are formed; sometimes sloughing of the skin takes place to a considerable extent, and colliquative diarrhoea often carries off the patient, exhausted by the slow fever and great suppuration." (Cazenave) In some instances where cellular inflam- mation and suppuration take place beneath aponeurotic membranes, the symptoms become still more violent and distressing. In cases of this kind, " violet spots appear on the inflamed skin about the second or third day ; these spots increase rapidly, and become covered with vesications; finally, small eschars are formed, which gradually fall off, and convalescence takes place under a greater or Jess degree of suppuration." This variety of the disease is sometimes attended with strong symptoms of disorder of the biliary system, constituting the erysi- ERYSIPELAS. 491 pelas phlegmonodes biliosum of some of the continental writers. Although not an uncommon modification, it has been but little no- ticed by the English writers. Mr. Copeland Hutchinson is, I believe, the only one who has given a particular account of it in the English language. There is, generally, much bilious vomiting in the com- mencement of this variety of the disease, and throughout its whole course the symptoms of biliary disorder are very conspicuous; the tongue is covered with a brown fur; the tunica albuginea is tinged with bile; and the skin generally exhibits a more or less icterode hue. The fever is of the synochus grade, and suffers very distinct evening exacerbations and morning remissions. The urine is small in quantity, and highly charged with bile; and in many instances bilious diarrhoea attends. Phlegmonous erysipelas may occur on any part of the body, but it most commonly appears on the extremities and face. Bateman says that it most frequently occurs in the face ; but Cazenave states that it is most frequently observed on the extremities, and this accords en- tirely with my own observations. In some cases, the erysipelatous inflammation is early accompanied by an oedematous state of the affected part; and this is more particu- larly apt to be the case, when the disease attacks persons of a relaxed and leucophlegmatic habit, or in such as have suffered much from chronic disorders, or are habitually intemperate. It would seem that in cases of this kind, the capillary vessels of the cellular tissue are, at first, in a highly congested, but not inflamed condition, and that these vessels soon relieve themselves by pouring out serum into the cellular structure. This modification makes its attack more mildly, and is, upon the whole, less dangerous and distressing than the preceding variety; although sometimes attended with considerable danger when it attacks the face. The inflamed skin is pale red, or yellowish brown, and is attended with but a moderate degree of heat and burning pain. The tumefaction does not increase so rapidly as in the phlegmonous state of the disease, and exhibits a smooth and polished surface, and pits when pressure is made with the finger. The vesicles are very minute, numerous, and but little elevated. On the second or third day after their appearance, they break, and give rise to thin, dark-coloured scabs. When the disease attacks the face, the swelling often becomes so great as to close the eyes, and render the whole face exceedingly bloated, giving it the appearance, as Willan observes, " of a bladder distended with water." In this case, too, considerable vomiting sometimes occurs at an early period, and in the height of the inflam- mation, delirium and coma occasionally supervene, and death takes place under symptoms of cerebral oppression. This modification of the disease is usually denominated erysipelas ozdemalodes. When the disease occurs in weak and nervous individuals, it is apt to assume a typhoid character,and is generally accompanied with low delirium throughout the greater part of its course. In instances of this kind, the inflamed part is of a dark or livid colour; the vesicles are not numerous but large, and frequently terminate in gangrenous ulceration. Suppuration and sloughing of the cellular tissue usually 492 ERYSIPELAS. take place, " producing little caverns and sinuses, which contain an ill-conditioned pus." This constitutes what is termed by authors ery- sipelas gangrenosum. In the year 1716, gangrenous erysipelas pre- vailed epidemically at Toulouse; and a similar epidemic is said to have prevailed in France in 1830. (Reil.) Infants are subject to a modification of erysipelas (E. neonatorum) of a very obstinate and dangerous character. It usually occurs soon after birth, and instances are related of children having been born with blotches of erysipelatous inflammation so far advanced as to exhibit vesication and spots of gangrene. (Richter, Bateman.) The inflammation almost always commences on the lower part of the body—particularly about the genitals, nates, and umbilicus, and gra- dually spreads over the abdomen, and along the back and inside of the thighs. In some instances, several parts are affected at the same time, without a confluence of the inflamed blotches. The inflamma- tion begins by a small red spot, which rapidly spreads irregularly over a greater or less extent of the skin. The inflamed part swells con- siderably ; is firm and extremely painful to the touch, and of a dark red or purplish colour. Large but thinly scattered vesicles appear, having inflamed livid bases, tending often rapidly to sphacelus. The disposition to gangrene is indeed always very considerable in this variety of erysipelas, particularly on the abdomen ; when it affects the extremities, ulcerative suppuration is apt to ensue. Symptoms of intestinal and hepatic disorder are scarcely ever wholly absent. The alvine discharges are usually frequent, painful, and grass-green ; in some cases there is constipation, with colicky affections. A jaun- diced appearance of the skin, aphtha in the mouth, and acid ejections from the stomach, are very common in this disease. Its course varies from about seven days to three weeks. When deep incisions are made into the affected parts after death, a large portion of thin serous fluid issues,* and the skin exhibits a firmer and thicker structure than in the natural state. Meckel found the umbilical vein, together with the peritoneum, inflamed, and he was led, by this fact, to believe that inflammation of this vein, occasioned by rude management in cutting and tying the umbilical cord, constituted the primary disease. This opinion has since been adopted by many, but its correctness as yet is by no means established. (Reil, Fieberlehre, b. ii, kap. 5, s. 329.) Richter observes that this disease in its general character is never purely inflammatory, but always manifestly gastric and irritative. There is another affection which appears to be very closely allied to the present one, if not in reality the same disease, and which is equally confined to new-born infants. This is the induratio lelse cellularis, an affection characterized by a peculiar hardening, con- solidation, or induration of the cellular tissue. It is not often met with in private practice, but in some of the foundling hospitals of Europe it has been abundantly observed. The affected part becomes hard, incompressible, and tense ; the skin so firmly adherent to the subjacent parts, that it cannot be pinched up, or in any way moved * Osiander. Denkwurdigkeiten, b. ii, st, 2, s. 370.—Neue Denkwurdi^k., b. i, 6. 56. ° ERYSIPELAS. 493 from its fixed position. Its colour is violet, pale red, yellowish red, or yellow. It generally commences on the trunk, and gradually ex- tends its circle, until, in some instances, the whole body becomes aflected. The little patient cannot cry out; deglutition is often diffi- cult, spasmodic, and occasionally impossible ; the jaws are sometimes closed as in trismus ; and in most cases, convulsive or tetanic spasms ultimately come on. Its course is always rapid—terminating often by the third day, and seldom continuing beyond the seventh. It is a most fatal malady. I have seen five or six cases, but no recovery. There is also an habitual and non-febrile form of erysipelas. It occurs in cachectic persons, in women of a leucophlegmatic habit labouring under menstrual irregularities, and especially in individuals affected with chronic visceral disease, more particularly of the liver. Habit- ual drunkards also are very liable to this form of the disease, no doubt from the hepatic disorder which is almost always ultimately produced by habitual intemperance. Although erysipelatous inflammation most commonly terminates in resolution, yet suppuration and gangrene frequently occur in the more violent grades of the disease. There is something very pecu- liar, however, in erysipelatous suppuration, both with regard to the seat of this process and the character of the pus which is formed. It always commences in the subcutaneous cellular tissue, and the pus generated is very rarely thick and yellowish like that in common phlegmonous suppuration, but thin, grayish or whitish, somewhat acrid and sanious. The matter is never collected in circumscribed cavities: it travels along the cellular tissue, under the skin, and be- tween the muscles until this structure (cellular) is almost entirely destroyed in the affected part. Small openings finally ulcerate through the skin, and the matter, mixed with shreds of sphacelated cellular membrane, is discharged. Through these orifices large portions of deadened cellular structure may be drawn," resembling pieces of wet tow." I have, in two instances, known this tissue so completely destroyed in the forearm, that the skin hung .loose like a bag round the muscles, and the muscles themselves were completely separated, as if they had been dissected from each other. Both cases termi- nated fatally. In instances of this kind that finally get well, the skin grows fast to the muscles, and even the muscles themselves adhere to each other, rendering their action very difficult, and sometimes de- stroying the free use of the limb entirely. Erysipelas, of whatever variety it may be, is always more dan- gerous when it attacks the head than when it occurs on the body or the extremities. This arises chiefly from the brain being apt to be- come oppressed or inflamed in severe cases of the face. Instances occur, in which the inflammation passes down into the fauces and along the alimentary canal, giving rise to severe and exhausting diar- rhoea. Visceral inflammations of various kinds have been known to supervene during the progress of severe erysipelatous affections. I have seen a case in which pneumonia came on during the height of the disease; and instances are related, in which the inflammation extended along the vagina into the uterus, as well as along the uri- 494 ERYSIPELAS. nary passages to the kidneys.* (Frank.) The brain, however, is by far the most frequently affected in this disease. Does this arise from metastasis of the external inflammation ? This point has been much disputed. Cullen ascribes the cerebral affection to the mere extension of the inflammation from the external part to the brain. This I believe to be correct. I have seen at least half a dozen cases in which symptoms of cerebral inflammation came on; but in no in- stance was the external inflammation in the smallest degree lessened by this occurrence. It is from the state of the brain, when the disease attacks the face, that we chiefly collect the prognosis. When neither delirium nor coma supervenes, either before or during the presence of the inflammation, there is generally no cause to apprehend particular danger; but when these symptoms come on, the hazard is always great. I am by no means disposed to deny that erysipelas sometimes passes, by metastasis, from the external to internal parts—or perhaps, more correctly speaking, that visceral inflammation sometimes super- venes at the same time that the erysipelatous affection disappears. I have myself recently seen an instance of this kind. A lady became affected with erysipelas on both arms occupying the whole surface . from the hands to the elbows. On the third day the inflammation rapidly subsided, and on the following morning she was seized with alarming haemoptysis. Richter observes that the oedematous, and what he calls nervousfi modifications of erysipelas, are the most liable to pass upon internal organs. What I have hitherto said, has reference chiefly to the local ery- sipelatous affection. In relation to the character of the attending fever, important diversities occur, which it may be proper to notice more particularly than has already been done. The most common grade of erysipelatous fever is the synochal, or strictly inflammatory. In some instances, the fever, in its onset, mani- fests a typhoid tendency, but as soon as the inflammation appears, its synochal character becomes developed. More commonly, however, the fever begins at once in the character of a well-characterized synocha; and this is more particularly apt to be the case in the phlegmonoid variety of the disease. In nearly all instances in which the inflammation attacks the face, the attending fever is of this grade; and it is of course always more apt to assume this grade in the young, plethoric, and robust, than in aged, infirm, and relaxed individuals. When the fever is synochal, it always increases in violence when the inflammation appears.:}: Not unfrequently the attending fever is typhoid, ab initio, and throughout. This is most apt to be the case in weak, nervous, and * Red, loc. cit., vol. ii, p. 372. t He designates those cases by the term nervous, that are attended with a ty- phoid or typhous grade of fever. They are generally connected with manifest gastric derangements. X [Erysipelas in this latitude often partakes of the intermittent type. In most cases the quinine and other tonics come in as the proper remedies after suitable evacuation.—Mc] ERYSIPELAS. 495 irritable subjects, and particularly in those who are affected with de- rangement of the digestive organs. Cases of this kind are always much more dangerous than where the fever is of a more active grade ; for they are equally liable to the supervention of internal inflamma- tions, and the occurrence of gangrenous suppuration is much more common in the former than in the latter, and of course, the system less capable of sustaining the effects of the disease. Typhous, or as it has been called, malignant erysipelas, has occa- sionally prevailed epidemically. De Haen and Bartholini mention epidemics of this kind, and I have already referred to the epidemic which prevailed at Toulouse in 1716, which is said to have been but little less fatal than the plague.* Causes.—In relation to the causes of erysipelas, nothing very defi- nite can be said. Some individuals appear to be constitutionally pre- disposed to this affection ; and Richter supposes that this predisposi- tion depends on a peculiarly irritable and delicate condition of the dermoid system. In some persons, bruises, wounds, and other local irritating causes, are particularly apt to give rise to erysipelatous in- flammation, and this is more especially the case in injuries of the scalp. The inflammation which is produced by the recent leaves of the rhus toxicodendron, is strictly of an erysipelatous character. Individuals of a cachectic habit; the habitually intemperate in diet and spirituous drinks; the leucophlegmatic; and persons labouring under chronic visceral affections, particularly induration of the liver or spleen, or mesenteric glands, are. most liable to this disease. Strong and sudden mental emotion has been known to produce erysipelas. Richter observes that he has known individuals who always became affected with erysipelas of the face, after they had been thrown into a violent fit of anger. (Therapie, bd. ii, p.*210.) In some individuals, ery- sipelas returns periodically. (Reil.) These cases are generally slight, and soon go off; and are usually dependent on some disorder of the liver or alimentary canal. Erysipelas seems at times to depend on some peculiar atmospheric constitution or miasm, for it is only to a cause of this general character that we can ascribe its occasional epi- demic prevalence. Some writers of eminence assert, that the disease is sometimes propagated by contagion; and there are many facts re- corded which strongly favour this opinion. The disease has, for instance, been known to prevail to a great degree in certain wards of hospitals ;t and Dr. Wells has brought forward some examples which occurred in private families, that appear to demonstrate its occasional contagious character.^ Dr. Stevenson, also, has recorded * Hippocrates mentions an erysipelas which spread among the people, and proved exceedingly fatal. The whole arm, leg, &c, had their soft parts in some instances almost entirely destroyed by gangrenous ulceration.—Van Swieten's Com- ment., vol. v, p. 181. t "The occasional contagious character which erysipelas assumes, is well- known to all who have paid any attention to the complaint in the wards of hos- pitals."— Dr. Johnson, Med. Chir. Rev., October, 1826, p. 404. X Transactions of a Society for the Improvement of Medical and Chirurgical Knowledge, vol. ii, 1800. (Bateman.) 496 ERYSIPELAS. some facts of a similar import.* Its occasional apparent Contagious character in hospitals may depend, however, merely on a general depraved habit of body, produced by the foul air to which the inmates of hospitals are at times exposed from deficient cleanliness and ven- tilation. Bateman states that this disease has been banished from the RoyaJ Infirmary of Edinburgh, by ventilation and other means of purification. Erysipelas occurs sometimes in the course of fevers, apparently from a critical effort of the system to relieve itself from some internal irritation. I have lately witnessed an interesting example of this kind. A person was seized with fever of a remitting synochus form. The disease was attended with symptoms of much gastric and biliary derangement. It continued without any amendment for nearly two weeks. At last a violent erysipelatous inflammation occurred on the face, which, in the course of six days, subsided regularly, and left the patient in a state of convalescence. This disease appears also at times on the suppression of some habitual evacuation. I know a gentleman in this city, who has been affected, for thirty years past, with an extensive superficial ulceration on one of his legs. When- ever the ulcer becomes dry, which generally occurs several times during the year, either an erysipelatous inflammation occurs on the face or the forearms, or he is seized with a violent fit of asthma. On the application of a blister to the leg, these affections speedily go off. Treatment.—With regard to the general treatment of this disease, it is obvious that it must be modified according to the character of the attending fever; and that a course of remedial management, which might be very proper in one modification of the malady, would probably be very injurious in another. When the fever is of a high grade of reaction, the treatment should be antiphlogistic. It is not, however, often necessary, even in cases of this kind, to make frequent and copious abstractions of blood — unless symptoms of cerebral inflammation supervene, with an active state of the circulation. Under such circumstances, blood should be promptly and freely drawn, in order to relieve the brain. It does not appear, however, that any par- ticular impression is often made on the progress of the erysipelatous affection itself—at least not on its obvious condition—by venesection; although unquestionably frequently very useful in obviating some of the unfavourable consequences of the inflammation. When the pulse is frequent, tense and hard, bleeding ought by all means to be prac- tised, and carried to the extent that may be indicated by the state of the circulation, without any regard to the appearances or character of the local affection. With regard to the propriety of local bleeding by leeches, very discrepant sentiments are expressed by authors. Willan, Thompson, Richter, and others, speak decidedly against this practice ; and from what I have myself seen of it, there appears to me much foundation for rejecting it. In the only case in which I have employed leeches, several very obstinate ulcerations occurred, apparently in consequence * Transact, of the Med. Chir. Soc. of Edinburgh vol. ii art. i ERYSIPELAS. 497 of the leech-bites. Cazenave speaks favourably of this mode of depletion; but he very properly cautions against applying the leeches to the inflamed surface. It must be observed, however, that although some advantage may be derived from the application of leeches a small distance from the eruption, yet as the inflammation is apt to spread, this will not always obviate the evil consequences which are apt to result when they are applied to the inflamed part. Purgatives are useful in every variety of the disease. When the disease attacks the face, they are particularly serviceable. In the ordinary phlegmonoid form, the saline purgatives are in general the best; but where symptoms of gastric derangement attend, calomel, in small and repeated doses, assisted by an occasional saline aperient, is preferable. In the bilious modification, the exhibition of an eme- tic will often prove very useful. After the operation of the emetic, large doses of calomel should be given, until the bowels are freely moved. Reil says, that in cases attended with fever of a synochus, inclining to the typhoid grade, emetics are highly serviceable. " If the disease has continued for some days, and the more direct an- tiphlogistic remedies may no longer be deemed proper, and the inflamed part assumes a pale yellowish hue, and is somewhat oede- matous, with but a moderate degree of heat and pain, emetics will generally arrest the progress of the disease effectively."* The regular action of the cutaneous exhalents should be supported by diaphoretics of the refrigerant kind. The saline mixture, with - a small portion of tart, emetic ; spiritus mindereri, according to the formula mentioned at page 176; or the sal ammoniac mixture men- tioned at page 127, will answer well for this purpose. Small por- tions of calomel and ipecacuanha in union, are peculiarly beneficial in this disease,! more especially in the erysipelas of infants.—Through- out the whole course of infantile erysipelas, our principal aim should be to restore the regular actions of the liver, alimentary canal, and of the skin; and hence calomel and ipecacuanha, in the proportions just mentioned, with an occasional dose of magnesia or castor oil, and warm bathing, constitute, so far as my own experience enables me to judge, the most useful course of internal treatment in this variety of the disease. When the attending fever is typhoid, direct depletion will of course be improper. In cases of this kind, bark and wine have been much recommended ; and where the symptoms of prostration are great, it will be necessary to employ them actively.J I have used cinchona * Fieberlehre, bd. ii, p. 398. t R.—Calomel gr. ii. Pulv. ipecac, gr. iii. Sacch. albi gr. xii.—M. Divide into twelve equal parts. S. One to be taken every four hours by an infant. X [In the low and irritable forms of erysipelas, especially of traumatic origin, I have seen brandy prove infinitely the best remedy. It is generally best, however, to combine Dover's powder or some other opiate with it, and also nutritious gruels or emulsions.—Mc] VOL. I.—32 498 ERYSIPELAS. in conjunction with the carbonate of ammonia, with much advan- tage, in a few cases of this kind. The quinine, however, would appear to be the best tonic in this modification of the disease. I have had occasion to prescribe it in but one instance of this kind, and its effects in this case were highly gratifying. But although tonics and stimulants are essential in cases of a low grade of reaction, mild laxatives are almost equally necessary. The bowels are almost invariably loaded with irritating matters, which, if not removed, tend strongly to oppress and prostrate the powers of the system. In instances of this character, it will be proper to exhibit laxatives conjointly with stimulants, and to continue the use of the latter, during, as well as after the operation of the former. In what is called the gangrenose modification of the disease, the fever always assumes a low grade in its progress, however active it may have been in its early stage. Where .manifestations of approach- ing gangrene come on, or where this process has already commenced, wine, opium, camphor, quinine* and the mineral acids, axe the remedies upon which our reliance must be placed. Free purging, with active doses of calomel, in the early period of the disease will, however, very generally render the necessity of tonics and stimulants in the latter stages, much less urgent than when this evacuation has not been sufficiently effected. It should always be recollected, in prescribing for febrile diseases, that intestinal irritation, from what- ever cause it may proceed, has a powerful tendency to oppress pr prostrate the vital powers; and that, under due precautions, the debilitating effects of purgatives are greatly exceeded by the increased energy imparted by the removal or diminution of such sources of the irritation. Should the inflammation terminate in suppuration and sloughing, opium and camphor, with quinine or cinchona, are indispensable in all cases. Opium is particularly valuable under circumstances of this kind, by allaying general irritation, and supporting the action of the heart and arteries. Opium may be given advantageously in combina- tion with quinine; and in several instances of extensive suppurative ulceration in this disease, I have known much benefit derived from the extract of conium, in union with camphor, given at short intervals, in full doses. Upon the whole, however, bark or quinine in large doses, and opium, may be regarded as the most useful supporters in such cases. Where the pain and irritation are great, opium, after proper eva- cuations, seldom fails to procure much relief. It should be given in full doses, at the same time that cold applications are made to the scalp and forehead. * This article has of late years been much recommended, and deservedly so, in erysipelas of a typhoid tendency. Sir Astley Cooper, in his Lectures, gives the following, as, in general, the most successful mode of remedial management. "At first, give calomel, for the purpose of restoring the secretions of the liver and intestines, and the liquor ammoniae acetatis, with antimony, to act upon the secretion of the skin, and then give the sulphate of quinine." ERYSIPELAS. 499 When secondary inflammation occurs in some internal organ, re- course must be had to local and general bleeding, if the pulse remain sufficiently active; and in all such cases, cupping, sinapisms, blisters, and the other usual revulsives, are indispensable. In cases attended with prominent cerebral disorder, such as deli- rium, coma,or insensibility, active purgatives and stimulating enemata are highly important means. For this purpose the ol. terebinth, has been found especially efficacious. Mr. Cox has given an account of a case of erysipelas of the scalp, face, and breast, which was attended with delirium, succeeded by coma and insensibility, with other symp- toms portending a fatal termination ; and which was successfully treated by the daily use of the turpentine combined with castor oil, both by the mouth and per antim. This medicine brought away large offensive stools, and from the first dose the symptoms gradually subsided.* Some diversity of opinion exists with regard to the propriety or usefulness of local applications to the affected part. Bateman ob- serves, "that with respect to external applications in the early stages of erysipelas, experience seems to have decided that they are gene- rally unnecessary, if not prejudicial;" and the same observation is made by Cazenave and Schedel. My own experience has led me to a different conclusion. I have certainly never seen the least injury done by suitable applications of this kind; but, on the contrary, often the most decided benefit. Formerly, physicians were much in the habit of applying cooling or relaxing remedies to the inflamed surface —such as lead-water, cold water, emollient poultices, fomentations, &c. That such applications should prove useless, and often injurious, may be readily admitted. There exists a close analogy between the inflammation of erysipelas and that produced by a scald or slight burn. In both, the capillaries of the inflamed part are debilitated, congested, and passively distended, and in both, therefore, the best applications are such as are capable of exciting or stimulating these vessels to increased tone and activity. For many years 1 was in the habit of using a solution of corrosive sublimate, in the proportion of about four grains to the ounce of water, and generally with a satis- factory result.t Pieces of linen or flannel moistened with this solu- tion, should be laid over the inflamed part, and renewed until the inflammation begins to subside. During the last four years, however, I have invarably used the nitrate of silver in solution, in the propor- tion of five or six grains to the ounce of water, and almost always with prompt and complete success. This solution is to be applied in the manner just mentioned for the sublimate wash. The mercurial ointment has been a good deal used in this country, as an application to erysipelatous inflammation. J I have myself employed it in several * Lond. Med. Repository, April, 1825. t I learned the use of this remedy in erysipelas from Dr. Schott. of this city. X This remedy was first introduced to the notice of the profession by Dr. Dean, of Harrisburg, although I have learned, that in the interior of this state, it was long before used in this affection by several respectable practitioners. Drs. M'Lel. lan°and Lewis employed it before Dr. Dean became acquainted with its use. 500 ERYSIPELAS. cases; in one,it proved very useful, but in the others, it afforded little or no advantage. It is to be applied by spreading it on pieces of linen, and laying them on the inflamed part. Dr. Brodie, of London, from some experiments he made with this ointment, came to the conclusion that its good effects depended more on the adipose substance than on the mercurial oxide combined with it, and in subsequent trials, he used only simple ointment, which, in some instances, he says, proved quite as useful as the mercurial unguent. Lard has also been used in this city, and it is said with considerable benefit. Brodie objects, and with justice, to the mercurial ointment, on account of its tendency to produce salivation; for in other respects, " its utility seemed unquestionable." Dr. Dewees also speaks favourably of this ointment, but makes the same objection to its use. Some of the Eng- lish surgeons speak very favourably of an ointment, composed of equal parts of ceratum calaminse, ceratum saponis, and unguentum plumbi acetatis. In St. George's Hospital, it has been used with evident benefit in traumatic erysipelas of the scalp.* Blisters applied to the, inflamed surface, will often promptly arrest the progress of the inflammation. Dupuytren speaks favourably of this practice, and it has long since been a favourite remedy with many practitioners both in this country and in France. My own experience enables me to say very little of this application. I have resorted to it only in two cases; one of these terminated in extensive suppurative ulceration; the other was benefited by it. Blistering is said to be most useful where there is but a moderate degree of febrile reaction, with a moist and "slightly red tongue, and a somewhat hot and tense skin. The blister must be laid directly over the inflamed part, and be large enough to extend a small distance on the sound skin. Velpeau and Bretonneau recommend compression by bandages in phlegmonous erysipelas; and their statements do not permit us to doubt that, in some instances, at least, much benefit may be derived from this practice. When the disease affects one of the extremities, compression may be easily made; but in the face it is impracticable. It is only in the early stage of the complaint, before vesication occurs, that this practice can be advantageously or safely adopted. In a case which I have attended within the last eight days, I had a satis- factory illustration of the usefulness of this measure. Nevertheless, statements have been published unfavourable to this practice; and Cazenave apprehends, though apparently not from any experience, much mischief from it. Several late English writers recommend making incisions through the inflamed skin and subjacent adipose and cellular textures. Mr. * [Of late the tincture of iodine has been a fashionable application to the sur- face of a part affected with erysipelas. The strong Lugol's solution of iodine is also employed by many. It appears to be quite as efficacious as the solution of nitrate of silver in allaying the irritation, and in checking the progress of the disease. But the red discoloration is quite as disagreeable, and as long of duration as is the blackening of the lunar caustic.—Mc] ERYSIPELAS. 501 Lawrence, who strongly recommends this practice, asserts, that »these incisions are followed, very quickly, and sometimes almost instantaneously by relief, and cessation of the pain and tension;" and a corresponding declension of the inflammation almost always takes place. Mr. Lawrence confines this practice to cases of the phlegmonous kind. Mr. Hutchinson also speaks decidedly in favour of making incisions into the erysipelatous surface. Mr. Lawrence recommends making one free incision, extending from one boundary to the other, through the centre of the inflamed part. Mr. Hutchin- son, on the contrary, considers it better to make a number of smaller incisions, about an inch or an inch and a half in length, through the skin and cellular structure. Mr. Dobson, who likewise advocates this practice in a modified form, advises a great number of punctures to be made a short distance from each other, over the whole disk of the affected part. The experience of Mr. Plymsol, of the Glasgow Royal Infirmary, may also be cited in favour of this practice. " The practice of making incisions in erysipelas phlegmonodes," says Mr. P., "has been esta- blished in this infirmary for the last four or five years, and has in- variably proved successful; long incisions are generally preferred." That this practice is calculated to afford much relief in phlegmo- noid erysipelas attended with a due degree of constitutional energy, cannot be doubted. The incisions or punctures give exit to the blood congested in the vessels of the inflamed part, and thus contri- bute directly and strongly to the reduction of the inflammation and its attending affections. In the other varieties of erysipelas—and even in the phlegmonoid form attended with weak powers of vital resistance or a tendency to a typhoid condition, this practice is con- nected with considerable risk, from the tendency of the wounds to assume a gangrenous state. Some have indeed expressed much doubt as to the value or general propriety of this practice, even under apparently favourable circumstances; and several respectable writers speak decidedly against its employment. Mr. James states, that in the cases in which he tried incisions, he did not obtain all the, advantage which he was led to expect from Mr. Hutchinson's report of this practice. Several writers strongly protest against this measure, affirming that the wounds are apt to run into mortification.* Mr. James did not find this tendency to mortification so great as some appear to apprehend. * [This is a childish error of opinion. Incisions prevent mortification of the skin in the most depressed constitutions —Mc] 502 HERPES. CHAPTER XVII. MINOR EXANTHEMATA. Sect. I.—Herpes. The term herpes was formerly applied in a very vague manner; and the German writers still include under its head various chronic affections of the skin, which by the late English and French writers, are regarded as wholly diverse from each other.* Willan first em- ployed it in a different manner, and restricted its application to a distinct class of cutaneous affections, characterized by an eruption of vesicles, appearing in groups or clusters on an inflamed surface, "so as to present one or more distinct spots separated from each other by intervals of sound skin." In most instances, manifest constitutional disorder, such as languor, loss of appetite, restlessness, and occasionally febrile symptoms, with a burning or stinging sensa- tion, or deep-seated aching pain in the affected parts, precede the appearance of the eruption. There is a regular increase, maturation and decline, in the progress of the eruption, but the duration of its course varies from one to three weeks. The fluid in the vesicles is at first limpid, becoming opaque or whey-like and more viscid as the disease advances, and at last either concretes into brown crusts, or the vesicles break, and suffer it to escape, giving rise often to dis- agreeable and unmanageable ulcerations. The diagnosis of herpes is founded on the assemblage of the vesi- cles in separate clusters, the red or inflamed state of the skin upon which they are sealed, and the natural colour of the intermediate spaces of skin. These characteristics distinguish it sufficiently from erysipelas. From tetter (impetigo), eczema, and other forms of chronic eruptions, it differs in its purely vesicular form, its, more acute character, and particularly in the regular progress of the vesicles from their incipient transparent state to maturation, and finally scabbing. * Eichter arranges pfyri?sis. psoriasis, ecthyma, and various species of impetigo with the herpetic affections. His fourth species, herpes pv.stvlosus. comprehends the five varieties of herpes of Willan. The minute splitting of diseases, so common of late, may be regarded as of very doubtful advantage, both in a scientific and practical point of view. A careful comparison of many of these species—their variable character, and their frequent conversion into each other —shows at once the little foundation there exists for at least some of these sub- divisions. The affections arranged under the term herpes, by Willan, and others, are, however, sufficiently distinct in their character, and diverse from other analo- gous disorders, to require separate consideration; and it is of little consequence what name they bear, provided they are properly described and understood. herpes phlyctenodes. 503 Herpes admits of being divided into different varieties, according to the particular form of the vesicular clusters, and the part of the body upon which they appear. 1. Herpes Phlyctenodes. This variety of herpes may occur on all parts of the body, having no determined form or seat. The appearance of the eruption is usually preceded, for several days, by slight febrile symptoms, and these sometimes continue after the vesicles have come out. On the part which is about to be the seat of the eruption, we may at first notice a multitude of very minute red points. In the course of twenty or twenty-four hours more, the skin upon which these points appear becomes uniformly red, and small transparent vesicles make their appearance. The cutaneous efflorescence extends a few lines beyond the margin of the vesicular group; and the vesicles themselves are firm and resisting to the touch during the first day. A sense of smart- ing, and occasionally a dull and severe pain, accompany the appear- ance of the eruption.—(Cazenave.) The eruption most commonly occurs on the upper parts of the body, particularly on the neck, breast, arms, and cheeks. It con- sists of small transparent vesicles, aggregated into irregular clusters of various sizes, from a few to nine or ten inches in circumference. These vesicles are sometimes very minute, and at others they are as large as a small cherry. In some instances they come out at first on the neck or breast, " and gradually extend over the trunk to the lower extremities, new clusters successively appearing for nearly the space of a week." This gradual extension of the eruption occurs very rarely, however, except in cases where the vesicles are very minute. In general, the eruption is confined to one or two groups when the vesicles are pretty large. About the fourth or fifth day the vesicles either burst and give exit to the included fluid, or they begin to wither and concrete into yellowish scabs, which usually fall off about the eighth or tenth day, and leave a red and irritable surface. When the eruption appears in successive groups on different parts, the disease will of course be proportionably prolonged ; for each cluster passes regularly through its stages of maturation and scabbing. However contiguous the groups of vesicles may be to each other, the intervening skin always retains its healthy appearance.—(Bateman.) Diagnosis.—The only affection with which the present form of herpes is particularly liable to be confounded is pemphigus; but an attention to the circumstance that the vesicles in pemphigus are usu- ally large, and always isolated—or at least not aggregated in clusters— and that they are very rarely attended with a red or inflamed basis, (unless where the bullae are nearly in contact with each other,) will enable us without difficulty to distinguish these affections. Causes.—Children, and young and robust persons, appear to be most liable to this affection; but of its predisposing and exciting causes we have no definite knowledge. Cold, improper nourishment, or an 501 HERPES ZOSTER. excess of food, grief, watching, and irritation in the prima? viae, have been supposed to exercise an agency in its development. 2. Herpes Zoster.—Shingles, Zona. This disease bears a very close resemblance to erysipelas, and was generally regarded as a mere variety of this affection, until Willan pointed out its distinctive characters, and placed it with the herpetic eruptions. This form of herpes is characterized by a band of vesicles, seated on a red or inflamed surface, commencing usually either in the right hypochondrium or lumbar region, and extending like a belt towards the fore part of the abdomen, without, however, crossing the median line. In some instances this band of vesicles passes down to the groin; in others it passes upwards to the inferior angle of the scapulae, and sometimes extends to the internal part of the arm, "running down occasionally to the cubital border of the hand." This eruption does not often occur on the left side of the body; indeed I have seen but very few instances of its location on this side. Velpeau,* and Brendel, however, assert the contrary. The former saw but one instance of its occurrence on the right side, out of thirty cases. The majority of writers, nevertheless, affirm that it generally makes its appearance on the right side, and my own experience is strongly in favour of this observation. It has never been found to occur on both sides at the same time. These vesicular zones are composed of irregular groups, from one to three inches in diameter; and where the clusters are not very close to each other, the interme- diate skin retains its healthy colour. The extension of the band does not occur by a regular succession of vesicles, but by successive new clusters coming out nearly in a line with the first. This, like the preceding variety of herpes, is generally preceded for a few days with loss of appetite, lassitude, slight headache, nausea, more or less febrile irritation, " together with a scalding heat and tingling in the skin, and shooting pains through the chest and epigastrium." In some instances, however, little or no constitutional symptoms can be perceived.t At first vividly red blotches appear arranged into an irregular belt, a short distance from each other. Upon these inflamed surfaces, a number of small whitish points appear, vvhich soon increase in size, and become distinct transparent vesicles " of the size and appearance * Revue Medicale, December, 1828. f Cazenave and- Schedel observe, " We have seen a great number of instances of zona in the Hospital St. Louis, and have never seen it accompanied with those general symptoms, and particularly of a gastric nature, with which it has been asserted it is always attended; a state of uneasiness, in some rare cases a slight excirement of pulse, heat of the skin, a sensation of tension, which is generally painful about the seat of the eruption, acute pain in those parts where the disease terminates in ulceration, and finally a slight local pain, remaining some time after :he eruption has disappeared, (not acute as has been said.) are the only phe- nomena, which, in a majority of cases at least, accompany this variety of herpes.;; —Practicd Sunopsis, p. 104. HERPES ZOSTER. 505 of small pearls." These vesicles increase in magnitude until the third or fourth day, when they acquire a yellowish or milky appearance, and on the following day begin to shrivel, at the same time that their bases acquire a darker red, or bluish colour. The vesicles about this time break and discharge a viscid serous fluid which dries into brown- ish crusts, which fall off about the tenth or twelfth day. Sometimes excoriations and occasionally superficial ulcerations occur, leaving strongly marked cicatrices. The disease does not, however, always pursue this regular course. In some instances the vesicles dry up about the fifth or sixth day— the fluid in them being absorbed—and terminate without scabbing, by desquamation. In old and enfeebled subjects, the eruption has been known to terminate in gangrenous ulceration of the skin. Causes.—Zona is most apt to attack young persons ;* and it is said to occur more frequently in males than females. (Bateman, Cazenave.) Reil asserts that this affection has never been observed in children under three years old. It seems occasionally to arise from the influence of cold; and some have ascribed its occurrence to irritation of the urinary organs. (Reil.) Disorder or irritation of the prima3 vise, and perhaps of the biliary organs, has appeared to me in some instances to be at the root of the disease. It is said to have prevailed epidemically. (Cazenave.) Prognosis.—This form of herpes is but rarely attended with severe symptoms. When it terminates in ulceration it may be- come troublesome ; and the occurrence of gangrene, which, how- ever, is very uncommon, will of course be attended with more or less danger, according to its extent and the patient's constitutional vigour.t ; Treatment.—The treatment of herpes phlyctenodes and zona, is to be conducted on the same principles. Gentle aperients, a simple and unirritating diet, and rest, will, in general, suffice for the consti- tutional treatment. When there is considerable restlessness, and some degree of febrile irritation, we may prescribe mild diaphoretics and cooling acidulated diluents. Where there is reason to suspect gastric or biliary irritation, minute portions of calomel and ipeca- cuanha will be proper. The warm bath will also be useful to allay restlessness and dispose to a regular action of the skin. Occasionally the arterial excitement is such as to warrant small abstractions of * We often meet with perplexing discrepancies in the statements of different writers, on points, too, which are matters of mere observation. Thus in the pre- sent instance, Red's observations are directly opposed to those of Willan, Bateman, Cazenave, and others. " Of the causes of zona, we know at least that those who are most subject to it are old and cachectic persons, with a relaxed skin and vis- ceral disorders." Fieberlehre, bd. v. p. 399. My -own observations, however, lead me to the opinion expressed in the text upon this point. t In relation to the prognosis of this affection, we find very different sentiments expressed by the old writers. Pliny, Lannge, Dr. Hoffman, and Shulze, considered it as a dangerous disease; whereas Burserius, Vogel, Lorry, and Diel assert the contrary opinion.—Reil, loc. cit., vol. v., p. 400. 506 HERPES CIRCINATUS. blood by venesection or leeching. Reil recommends particular at- tention to the renal functions, and advises diuretics where the urinary secretion is scanty. Where there is much deep-seated pain, we may use full doses of Dover's powder with benefit. Bateman considers external applications unnecessary during its vesicular state ; and Cazenave asserts that " they are useless." My own experience has led me to a different conclusion. It is indeed true, that '• saturnine and other similar astringent lotions" are of little or no service. I have, however, uniformly found the applica- tion of a solution of lunar caustic, in the proportion of six or eight grains to an ounce of water, when employed soon after the vesicles appear, to arrest the progress of the eruption, and cause desquama-- tion in the course of three or four days at furthest; and sometimes much earlier. I have never known the slightest inconvenience to result from this practice. I keep this solution constantly applied to the affected part, by strips of linen or flannel saturated with it.* M. Velpeau, also, has expressed the most favourable opinion of the powers of this application in zona. He affirms that when applied before ulceration has taken place, it never fails to arrest the progress of the malady, and, so far as he has observed, always without un- favourable consequences.t 3. Herpes Circinatus.—Ringworm. This form of herpes is easily recognized by the annular arrange- ment of its small vesicles. It commences with slight redness and itching, succeeded by a circle of minute globular vesicles closely set together, which, when closely examined, are found to contain a colour- less fluid. These coronae of vesicles vary from an eighth of an inch to two inches and upwards in diameter, and the larger ones leave the central portion of the skin apparently in a natural state. The vesicles break in four or five days after their appearance, and are succeeded by little prominent, brownish, and thin crusts or scales, which in the majority of cases fall off about the eighth or ninth day, leaving a red surface which gradually disappears. Occasionally the whole disk of the circle is somewhat inflamed, "and a slight desquamation occurs without the formation of vesicles." When the circles are very small, the eruption withers, and gradually exfoliates without the formation of crusts or scales. Although the eruption is seldom protracted beyond the tenth day, yet in many instances new circles of vesicles appear, in succession, so as to prolong the whole course of the disease for several weeks. The eruption is always attended with a troublesome itching and tingling sensation This variety of herpes is most frequently met with in children, and occurs generally on the arms, shoulders, breast, and especially on the neck and face. * The lunar caustic was, I believe, first used as a local application, in this affec- tion, by M. Geoffroy.—Revue Medicale, April. 1820. f Loc. citat., p. 435. HERPES LABIALIS. 507 This disease must not be confounded with a somewhat similar affection which occurs only on the scalp, (porrigo scutulata.) and which is familiarly known by the term hair-worm. This disease is contagious, destroys the hair, and is pustular. Its duration is inde- finite and long, and it gives rise to the formation of thick adherent scabs. There is a variety of ringworm, not noticed in the work of Caze- nave, though described by Bateman, which is by no means uncommon in this country, and which often continues for many months, and at last takes up a large extent of surface. It commences with a small circle of vesicles, like the form just described. This circle, however, gradually enlarges its circumference, by the successive appearance of new vesicles around the external margin of the ring, whilst those situated on its internal margin heal and desquamate. Treatment.—The treatment is almost exclusively local. Alka- line washes, such as a lotion of from one to two drachms of subcar- bonate of potash or soda to a pint of water ; or solutions of nitrate of silver, sulphate of zinc, or of copper. One of the best applications I have met within this affection, is an ointment made of the root of the common narrow-leafed dock, (rheumex c?^'spa,)'by boiling the grated root in lard. Mild laxatives should be used if the eruption is exten- sive. 4. Herpes Labialis. This is a vesicular eruption which occurs on the upper and under lips and particularly at the outer angle of the lips, extending some- times nearly round the mouth, and occasionally to the cheeks, alae nasi, and chin. In some instances this eruption .appears almost sud- denly, without any previous redness or disagreeable sensation in the part; and at others it is preceded by a slight tenderness or pain, in- flammation and swelling of the skin, for three or four hours. The lip generally becomes somewhat swollen, hard, stiff, and tender. The vesicles sometimes "attain the size of a small pea, and are filled with a transparent fluid," which soon becomes opaque, acquiring a straw colour, or sero-purulent appearance, during the third or fourth day. In the course of a day more they shrivel, and are succeeded by light- brown scabs, which usually separate on the seventh or eighth day. This eruption is always attended with very considerable heat and smarting, and soreness to the touch. This variety of herpes does not often occur as an idiopathic affec- tion. It generally appears on the subsidence of slight febrile affec- tions from cold, as well as on the declension of other acute diseases, more especially such as are connected with visceral affections. It may in fact be considered, in cases of this kind, as a phenomenon of crisis, for it is a common, and in general not an incorrect observation, that the occurrence of this eruption indicates the near approach of con- valescence. In many instances it is accompanied by coryza, and pain or tenderness in the fauces. It may be produced by irritating appli- cations to the lips. 50S HERPES PREPUTIALIS.— PEMPHIGUS. The only remedial applications necessary in this affection, are such as palliate the burning heat and pain, when these are troublesome. For this purpose, fomentations, with a decoction of white poppy heads, or cold water, with a small portion of acetate of lead dissolved in it, may be used. 5. Herpes Preputialis. This variety of herpetic disease occurs on the prepuce, and may readily be mistaken for chancre, to which indeed it sometimes bears a very close resemblance. It begins with one or more red spots, at- tended by itching, and a sense of slight heat in the part. Small vesi- cular elevations soon appear on these inflamed surfaces. When the eruption occurs On the external surface of the prepuce, the vesicles dry up about the sixth day, and are converted into small, firm scabs, which usually fall off' by the end of the ninth or tenth day, and leave the skin underneath sound. When the eruptions occur on the internal surface of the prepuce, they generally break out about the third or fourth day, and form small scales, which soon separate, and leave excoriations, passing sometimes into superficial ulcerations, with white bases, and slightly elevated edges. If left to themselves, or not irritated, these sores continue nine or ten days before they begin to heal, but when they once commence this process, they usually cicatrize rapidly. This affection may arise from the prepuce being chafed by woollen clothing; from the irritation of morbid vaginal discharges; and par- ticularly from suffering the natural secretions of the part to remain between the glands and prepuce. Treatment.—I have generally employed a solution of borax with much advantage in this affection. When the excoriations are slow in healing, a very weak solution of the nitrate of silver is perhaps the best application. I have used this solution in a number of cases with prompt benefit. The chloride of soda in solution is likewise a very efficacious application in cases of this kind. I have lately em- ployed this lotion in two obstinate cases with marked success. It was first recommended by Lisfranc. I used this article in the pro- portion of twenty grains to an ounce of water, and applied it five or six times daily. Sect. II.—Pemphigus.* The term pemphigus is used to designate a peculiar exanthema- tous affection, characterized by fever, followed in the course of from one to three days with large transparent vesicles, having red and * The first distinct account that was given of this disease, is to be found in the writings of Piso (observ. 149) and Morton (tract, de morb. acut.) It has since been described under a great variety of names—such as, febris catarrhalis vesi- cularis, (Delius. amcenitat. Med., dec. 1:) febris vesicularis, (Macbride and Selle, prax. medic, t. 11, c. 18:) febris pemphygodes, (Seeliger, Ephemer. N. C, dec. 1, PEMPHIGUS. 509 inflamed bases. The occurrence of such a disease, as an independ- ent or idiopathic affection, Iras been much doubted by many writers, and some have even denied its existence altogether. Willan, Bate- man, Plumbe, Reil, and a number of other writers, contend that the cases which are described by the early writers, as acute idiopathic pemphigus, were—typhus, pestilential, or other milder forms of fever, attended by bullae, as mere casual symptomatic and unessen- tial eruptions. Gilbert,* and Biett,t on the other hand, admit the occasional appearance of acute pemphigus, as an idiopathic malady. There can exist but little doubt that many of the cases described by authors as pemphigus, were-in relation to their vesicular character, purely symptomatic; for bullae entirely similar to those which are ascribed to this affection, have been known to occur in diseases obviously diverse in their general essential characters. They have occurred in intermitting fever ;J in bilious remittents ;§ in dysen- tery;! in typhus ;1T in various modifications of malignant as well as in arthritic fevers;** in hysteric affections;tt and in the ordinary catarrhal fevers, as well as in various other forms of febrile disease. Cazenave states that he saw a case in the Hospital of St. Louis, in which "this eruption was attended not only with gastro-intestinal irritation, but also with a pulmonary catarrh, and ophthalmia, and a very acute inflammation of the urethra. All these symptoms, together with the eruption, disappeared in the course of a month." It is dif- ficult to conceive upon what grounds he regards this as a case of idiopathic pemphigus ; for in its general course and phenomena it is greatly at variance with his previous description of this affection. Most assuredly, if this case deserves to be regarded as an instance of pem- phigus, we may with little hesitation admit the many supposed ex- amples of this disease, which have been reported by different writers (but rejected by Cullen, Willan, Bateman, and Reil) as genuine, though modified instances of this affection. .Under this perplexing contrariety of statements and opinions, it is no easy matter to come to any satisfactory conclusion on this head. That the appearance, of bullae, or large distinct vesicles, in febrile affections, is often casual or symptomatic, and sometimes apparently critical, is unquestiona- ble ;\x Dut ^ is nevertheless difficult to deny, merely from this general ann. viii, ob. 56;) febris phlyctenodes, (Burserius:) hydatides, (de morbis a colluVie serosa orta;) febris bullosa, (Brugmann.) * Monographic sur le Pemphigus. t Cazenave and Schedel. Pract. Synop. of Cutan. Diseases. X Braune. Versuch iiber den Pemphigus, &c. Leipzig, 1795. $ Salabert. Abhandl. fur prac. arzte, vol.xiii. II Bontius. De Medic. iEgyptiorum. Rengger. Museum der Heilkunde. Zurich, 1794. H Medecine Experimentale. ** Hufeland's Journal, vol. xi, p. 138. ft Frank. Epitome, tom. iii, p. 269. XX Frank saw an instance of inflammatory fever, in which, after the fifteenth venesection, a critical pemphigus broke out.—De Curandis, Horn. Morb. L. Ill, p. 265. 510 PEMPHIGUS. fact, that they may appear in an acute form as an idiopathic or inde- pendent malady. Whether, however, this eruption be always, or only generally symptomatic, I shall now describe it, as it has been observed and recognized for genuine acute pemphigus, by several recent writers, who must have been fully acquainted with the doubts expressed on this subject by Cullen, Willan, and others, and who, we may therefore presume, were better prepared to estimate the cha- racter of the disease than the early writers. Pemphigus appears under two distinct forms; the acute and the chronic. The latter form is described by Willan, Bateman, and other late writers, under the name of pompholix. Symptoms of acute pemphigus.—The disease commences with symptoms of general indisposition, or more or less febrile irritation. In some cases, the precursory symptoms amount only to a feeling of general languor and uneasiness, with slight acceleration of the pulse, and itching of the skin. In others, nausea, loss of appetite, slight chills, increased thirst, and great frequency of the pulse, with a hot and burning skin, precede the eruption. At an indefinite period from the commencement of these symptoms—varying from one to four days—the eruption makes its appearance. At first, small red circular spots come out, which speedily increase in size, each one be- coming covered with a transparent vesicle. These vesicles or bulla? are of a circular form, and vary from the size of a pea to that of a large hazelnut. Sometimes the bullae are much smaller than the red spots upon which they are seated, leaving a considerable inflamed margin around their base; at others, they cover nearly the whole surface of the circular spots, with only a very narrow line of red border. Cazenave and Schedel seem to regard these red areolae or bases as invariably present and strongly characteristic of acute pem- phigus. Richter, however, observes, that the bullae sometimes ap- pear to rise out of-a sound skin, without the least redness around their bases. Some spots occasionally appear on the skin which do not vesicate ; but to the touch they will be found slightly elevated, " and when they are rubbed for a short time, the cuticle becomes detached, and a slight exudation of serous fluid takes place under it." The bullae increase in size during the first twenty-four hours, and the contained fluid, at first limpid, becomes yellowish, and finally turbid.* They sometimes break on the second day ; but much more commonly they remain in a turgid state to the end of the third or beginning of the fourth day, when the fluid begins to be. absorbed, and the vesicles shrivel, leaving either thin brownish crusts or only " small dry, white epidermic lamellae, which in a few days longer separate, exposing pale red surfaces t If the bullae are broken at,an * This fluid has been noticed acrid or irritating, like the tears in violent catarrh. Occasionally it is reddish, as if a small portion of blood were mixed with it.— Very generally, however, it is perfectly bland and unirritating, at least in the early period of the eruption;—Richter, Specielle Therapie, bd. ii, p. 604. t The spots left by this eruption are said to be peculiar. •'• We have several times seen M. Biett draw a diagnosis from them as to the previous existence of PEMPHIGUS. 511 early period, they sometimes rise again, but more frequently super- ficial suppurative ulcerations ensue. (Richter.) The occurrence of the eruption has no manifest influence on the general symptoms, the fever continuing usually without any obvious change until the bullae begin to wither. (Richter.) The eruption may come out on any part of the body, and either occupy only a particu- lar region, or appear scattered over the greater part, or the whole surface of the body. In most instances, however, the bullae are con- fined, at first, to a single part; when these begin to disappear, another crop comes out on some other portion of the body ; and in this way, two or three successive eruptions may take place, so as to protract the whole course of the disease, sometimes to a period of between two and three weeks. The internal mucous- surfaces, also, are liable to become affected, particularly the mouth, fauces, and oeso- phagus, and probably the mucous membrane of the alimentary canal. The pompholix solitaries of Willan is, according to Cazenave and Schedel, a mere variety of acute pemphigus. This is an ex- tremely uncommon form of the disease, and may assume a more or less chronic character, although its usual duration is from eight to ten days.* Willan says that it seems to be entirely confined to females. A sensation of tingling of some portion of the skin is at first felt; this is succeeded by one large vesication, (appearing usually at night,) which is rapidly filled with a transparent colourless lymph. This large bulla breaks in the course of forty-eight hours, and leaves a superficial ulceration. In a day or two a second vesication occurs near the first one, which runs through the same course ; and a'third or even a fourth one may rise in succession, so as to protract the dis- ease to the ninth or tenth day. (Bateman.) Chronic pemphigus.—Willan and others who deny the existence of acute idiopathic pemphigus, describe the present variety of the disease as a distinct affection, under the term pompholix. They as- sert that the bullae appear " without any inflammation around them, and without fever." This, says Richter, is not entirely incorrect. In many cases the disease commences with distinct febrile symptoms, which continue occasionally until the first eruption is completed: and in some instances the slight fever reappears afterwards, when- ever a new and numerous eruption of bullae is about to take placet In almost all cases, the patient experiences a slight degree, of lassi- tude, pain in the limbs, and languor, for several days previous to the appearance of the eruption. Nor does the observation that the bullar eruption, which had been cured some time before. They are of a dull red colour, separated from each other, of an irregular form, of variable size, and form slight exfoliations from time to time."— Cazenave and Schedel, loc. cit., p. 129. * Cazenave, Synopsis, &c, p. 124. t Specielle Therapie, bd. ii, p. 613. Reil says that in some cases the febrile symptoms are conspicuous in the commencement, but that these gradually sub- side leaving only a chronic bullar eruption which continues often for many months and even years. Loc. cit., p. 428. 512 PEMPHIGUS. bulla) are always " without any inflammation around them," appear to be correct, for in some instances " the secondary eruptions have erythematous areolae." (Cazenave.) The bullae begin by small red elevated points, on the centre of which the epidermis becomes speedily raised. These rapidly enlarge "into irregular vesications, acquiring often in a few hours the size of a hazelnut or even a wal- nut." If they do not break, they begin to shrivel about the third or fourth day, the fluid contained acquiring a reddish and opaque ap- pearance. In a few more, the withered and macerated cuticle dries into thin brownish crusts. If the bullae break at an early period, " the cuticle, shrivels, or becoming partly detached, rolls up and lays bare a portion of the inflamed surface," or separates entirely, and exposes a painful superficial ulceration. (Cazenave.) This affection is generally very tedious in its course, and may con- tinue for several years. A continual succession of bullae occurs on different parts of the body, sometimes in successive crops, and at others in such a manner, that, at the same time, some will be just appearing, others will be large, and distended with a straw-coloured lymph, and others again shriveling, or already converted into small crusts. Occasionally the bullae are so numerous that many of them run into each other, and in this case some of them usually become purulent, and on drying up leave thin yellowish crusts extending over a considerable portion of the body. When the eruption is moderate, the patient does not in general experience much inconvenience from the disease; but in cases attended with numerous vesications, and particularly where the lymph is some- what irritating, a burning and extremely distressing itching is expe- rienced, which in violent cases sometimes obliges the patient to keep to his bed. In some instances the vesicles are early attended with severe burning pain, become filled with a red acrid humour, and terminate in superficial suppurative ulcers, which heal very slowly. Reil ob- serves, that bullae, containing bloody lymph, occur only about the ears, where previous vesicles have already occurred.* Wichmann relates a case in which, nine months after the commencement of the disease, he found the patient extremely tormented and debilitated by a great number of large ill-conditioned ulcerations on the lower extremities and sacral region. The ulcers appeared red, and the surrounding skin as if it had been scalded with hot water.t A some- what similar case is mentioned by Cazenave and Schedel. This affection may occur simultaneously on every part of the body; but in most instances the vesications are confined to a particular space. In the palms of the hands and soles of the feet they occur but very rarely. They have been observed on the internal surfaee of the mouth, the fauces, oesophagus, and the alimentary canal; in these situations they soon assume the appearance of aphthae. The tongue and fauces occasionally become excoriated in cases of this ■* Fieberlehre, bd. v, p. 418. t Beitrag zur Kenntmiss des Pemphigus. PEMPHIGUS. 513 kind. Colic; constipation; bloody and mucous alvine discharges; nausea; vomiting, or haematemesis, have been known to supervene in cases where the disease affected the alimentary canal. (Wich- mann, Reil.) " At times, it would seem as if the eruption on the external and internal surfaces alternated—the symptoms of the latter increasing as those of the former decrease, and vice versa."* Both Wichmann and Braune relate cases in which the mucous membrane of the bronchiae became affected during the progress of this malady. Several instances are mentioned in which cough and purulent ex- pectoration came on. Cause.—Of the etiology of pemphigus there is as yet but little known of a satisfactory or definite character. It is said to be more common in old than in very young individuals, and in women than in men.t Braune supposes that this affection is frequently dependent on deficient or disordered urinary secretion; (loc. cit., p. 59.) Habitual deficiency of this secretion, and obstinate chronic cutaneous disor- ders, are indeed not unfrequently associated affections. In one of the instances of chronic pemphigus, mentioned by Braune, the intimate connection between the action of the kidneys and the cutaneous affection was manifested in the clearest manner. Whenever the urine flowed freely, the bullae disappeared ; but they invariably reappeared when this secretion became scanty, watery, and muddy. Renal calculi were discharged from time to time with the urine. Richter, Wichmann and Reil also admit the frequent occurrence of renal dis- order in pemphigus. It would seem, also, that disorder of the liver is a frequent attendant on this disease—whether as cause or effect, is not known. Biett, in his dissections in the Hospital St. Louis, several times met with structural disease of the liver, in persons who had died under this disease. (Cazenave.) The irritation of dentition ; neglect of personal cleanliness; a defi- cient and coarse diet; habitual exposure to a damp atmosphere; and chronic visceral affections, would seem sometimes to favour the de- velopment of the disease. It arises, however, often without any perceptible cause, either predisposing or exciting. It is said to have occurred endemically. The same individual may be affected with it several times, at distant intervals. This disease is not contagious. Hall inoculated with lymph taken from the bullae without effect.^ Diagnosis.—Acute pemphigus is liable to be confounded with rupia simplex, ecthyma and herpes phlyctenodes. From the first of these affections it differs, by the bullae in rupia being few in num- ber, and followed by ulcerations, upon which thick and projecting scabs are formed. It is distinguished from the second by the bullae in ecthyma being less elevated, and filled with a purulent fluid, * Braune. Versuch tiber den Pemphigus und das Blasenfieber. Reil, loc. cit.. p. 420. t This at least is in conformity with the observations of Reil and others. Cazenave, on the contrary, says that the chronic form of the disease "rarely occurs in women." X Duncan's Annals of Medicine, for the year 1799. vol. I.—33 514 PEMPHIGUS. having a brownish spot in the centre of each. From the last disease it may be distinguished by the vesicles in herpes always appearing in clusters seated on a diffused red and inflamed surface. Although several bullae in pemphigus are occasionally found collected in one or more groups, yet distinct bullae appear elsewhere on the body, which is not the case in herpes. Prognosis.—The acute form never terminates fatally unless dan- gerous secondary affections supervene. In relation to the probable duration, ultimate violence, and obstinacy of the chronic form of the disease, the prognosis is in general very uncertain. Some cases con- tinue moderately for eight or ten weeks, and then disappear; others, apparently equally mild during the first four or five weeks, gradually acquire more and more severity, and continue for many months in an aggravated and very distressing form, and may even terminate fatally. The degree of danger depends, of course, in a great mea- sure, on the extent of the eruption, the obstinacy of its progress, the nature of the visceral affections with which it may be complicated, and the degree of constitutional vigour of the patient. Wlien the vesications assume a livid or bluish appearance, there is much reason to apprehend unfavourable consequences. (Reil.) Old, worn down, relaxed, arthritic and nephritic subjects, are most apt to suffer severely from this affection. Treatment.—In the acute form of the disease, it will in general be sufficient to put the patient on a simple and unirritating diet; to prescribe an occasional mild laxative; cool acidulated diluents; rest; and to avoid a humid and variable atmosphere. If inflammatory symptoms supervene, or the eruption is very extensive, a more active antiphlogistic treatment is required. Gentle purgatives; the ordinary saline diaphoretics, particularly the alkaline effervescingdraught(portio Riverii); tepid bathing, and venesection, must be used with an energy corresponding to the degree of the general and local inflammatory excitement present. Richter recommends calomel in such cases above all other aperients. He also advises the use of diuretics, if the disease manifests a disposition to continue beyond its ordinary course—and of these, he says, digitalis is the best, squills being, according to his experience, objectionable. All local applications must be avoided, nor should the vesicles be disturbed or opened. Cazenave recom- mends the application of leeches to the anus. In chronic pemphigus, (pompholix,) we should, in the first place, endeavour to ascertain whether any visceral or other general disor- ders co-exist, or preceded the eruption. Should there be grounds for presuming the presence of a syphilitic taint, or of an arthritic or calculous diathesis, or finally of hepatic or some other visceral affec- tion, recourse should be had to remedies suited to counteract the lurk- ing affection. (Richter.) In general, a moderately antiphlogistic treatment—such as acidulated diluents, mild aperients, and tepid baths, will be proper in the commencement. The German writers speak very favourably of the employment of diuretics in this variety of the disease. They are particularly indicated where the urinary secretion is scanty or unnatural. Richter says that he cured an URTICABIA. 515 inveterate case in a short time by the following mixture,* in conjunc- tion with the free use of an infusion of juniper berries. The same writer recommends dulcamara, in union with antimony.\ Lime- water in large portions ; infusions of herba jacea; sarsaparilla; pre- cipitated milk of sulphur; belladonna; and opium, have all been mentioned as remedies in this affection. I have met with but one case of chronic pemphigus. It continued for six months, under various modes of treatment, and at last disappeared under the use of Fow- ler's arsenical solution. When diarrhoea, with more or less obtuse abdominal pain, supervenes, opium is particularly serviceable. When pulmonary irritation occurs, attended with frequent and violent cough, spitting of blood, and oppressed respiration, local and general bleed- ing becomes necessary, after which opium and calomel may be ad- ministered with benefit. When, by the long continuance and severity of the disease, the strength of the patient is exhausted, or when the disease occurs violently in old, relaxed and worn down subjects, qui- nine, with the sulphuric acid; a nourishing diet; occasional opiates; chalybeate preparations; and other supporting remedies, should be employed. Cazenave and Schedel state that they have observed several examples in the Hospital St. Louis, of the very good effects of tonic remedies even in young subjects, where the eruption was of long continuance. Sect. III.— Urticaria.—Nettle-rash. The nettle-rash, a very common cutaneous affection, is character- ized by hard elevations of the cuticle, of irregular forms, with a pale or whitish centre, and generally a diffuse redness around their mar- gins, attended with intolerable itching, and a stinging or smarting pain. Its course is often very rapid, the eruption appearing suddenly, and vanishing again in the course of a few hours; although in such cases it usually reappears for several days in succession. It may also assume a chronic character, and continue, with occasional transient intermissions or remissions, for many months or even years. Urticaria febrilis.—Symptoms of general indisposition, such as nausea, languor, drowsiness, slight chills, headache, anorexia,pain and * R.—Extract, digital, purpur. gr. iii—iv—vi. Submuriat. hydrarg. mitis gr. i. Opii puriss. gr. ss. Sacch. albi gr. xv.—M. Divide into twelve equal parts. S. Take one three times dady. The proportion of digitalis should be gradually increased. If the "Tims become affected, the use of the medicine must be suspended for a while. —Loc. cit., p. 615. f 1£.—Antimon. crud. nigri. Pulv. stipit. dulcamara, aa 3L Extract, trifol. aquat. 3d — M. Divide into two grain pills. S. Take ten three times daily. 516 URTICARIA. anxiety in the epigastrium, with an accelerated pulse, precede the appearance of the eruption. At first, a general itching with a feeling of tingling heat is felt over the whole body; to relieve which, the patient is apt to rub or scratch the skin, which never fails to bring out, almost instantaneously, large patches of red elevations or wheals, with whitish central disks and irregular crimson areolae, attended with an extreme degree of itching and tingling. The eruption speedily becomes more or less extensively diffused over the surface, particu- larly on the palmar aspect of the forearms, around the knees, along the loins, on the inner part of the thighs, and on the shoulders. The eruption vanishes irregularly on different parts of the body, but is almost immediately recalled " on any part of the skin, by strong fric- tion or scratching." During the day the eruption subsides, but as the evening approaches, it returns, together with slight febrile irritation; and in this manner the disease is usually protracted to the sixth or seventh day before it finally subsides. The parts principally affected become swollen and uniformly red; but the swelling always soon subsides after the eruption disappears. More or less languor and febrile irritation accompany the disease throughout; " the disorder of the stomach, however, is relieved by the appearance of the eruption, but returns whenever the eruption reappears." (Bateman.) Urticaria evanida.—This variety of the disease is unattended by fever, and often continues for many months under a succession of transient wheals, appearing here and there on the body, and vanishing again in a few hours, at short and irregular intervals. An eruption will perhaps appear on one arm in the morning, and disappear again in a few hours; in the afternoon, the wheals may come out on the legs and remain for a short time ; and after a short interval, or only on the following morning, they may appear on the body. In this way the disease may go on to a very protracted period—the eruption appearing and disappearing frequently, " according to the tempera- ture of the air or the exposure of the patient, and the degrees and kind of exercise which he uses." The slightest friction or scratching will almost immediately bring out the wheals on any part of the body; but when thus excited, they usually recede again in a very short time. The eruption consists of irregular patches slightly raised and firm to the touch, or of elongated wheals, " like those produced by the stroke of the whip, or they are round, resembling the firm, elevated tumours produced by the bite of a mosquito." These wheals are not surrounded by an erythematous areola, although sometimes encircled by a very narrow and faint streak of red. They are always attended with violent itching, and a sensation of tingling or stinging pain, more particularly " on undressing and getting into bed." Lan- guor, headache, transient pains, and derangement of the digestive functions, are apt to occur during the course of the disease ; but in some instances scarcely any symptoms of constitutional or sympa- thetic disorder, except the cutaneous affection, attend. " Its course varies from a few days to many months, and even years." (Bateman.) Urticaria tuberosa. — This rare variety of the disease is charac- terized by hard, prominent wheals, or tuberosities, attended with deep- URTICARIA. 517 seated pain, tension, and difficulty of motion. The eruption occurs chiefly on the loins and on the extremities. It generally comes out at night, and disappears before morning, leaving the patient " weak, languid, and sore, as if he had been bruised or much fatigued." Caze- nave and Schedel state that they saw at the Hospital St. Louis, an instance accompanying a quotidian fever which, after having lasted for four years, finally terminated "in swellings, great distension, ecchymosis, ruptures and ulcerations." Some paroxysms were at- tended with so much general tumefaction, as to produce oppressed and hurried respiration, a livid and puffed face, weak and intermit- ting pulsation of the heart, and other very alarming symptoms. Urticaria subcutanea.—ln this variety the wheals seem, as it were, to lurk beneath the skin, and make their appearance only at distant intervals. An almost constant tingling sensation, however, is felt in the skin, with occasional severe pricking sensations, as if needles were thrust into the surface, limited at first to a single part, but extending afterwards to others. Individuals affected with this variety of the disease, are apt to suffer frequent pain in the stomach, and cramps in the muscles of the legs. (Bateman.) Causes.—Urticaria is most commonly met with in children, young females, and in persons of a sanguine and nervous temperament. The seasons most favourable to its occurrence are spring and summer. Some individuals are so strongly predisposed to the disease, that the least friction or scratching almost immediately brings out large wheals. The irritation of dentition, mental excitement, and various articles of food, such as strawberries, raspberries, mushrooms, honey, oatmeal, green cucumbers, almonds, dried or smoked fish, lobsters, shrimps, crabs, and particularly muscles,are apt to produce febrile urticaria in some individuals. The internal use of valerian and balsam copaiba produce extensive urticaria in some persons. Chronic urticarial i$ frequently connected with an irritable and deranged state of the digestive functions. The tuberous variety " seems to be excited by excess in diet, overheating by exercise, and the too free use of spirits." Urticaria is also produced by direct irritating applications to the skin, particularly by the leaves of the common nettle (urtica dioica) and by the contact of certain caterpillars, as the phalsena processionacea. It occurs sometimes in the course of various febrile diseases, and is often speedily prod uced by taking a draught of cold water after the body has been excited or heated by exercise. In many instances, how- ever, the disease makes its appearance without any manifest exciting cause; occasional dependence on peculiar idiosyncrasy or constitu- tional habit is unquestionable. In children it often occurs during the process of dentition, or apparently from acidity in the primae viae, and is in them usually called hives. Prognosis.—Although often an extremely tormenting affection, from the intolerable itching and stinging pain which attend, urticaria is almost universally wholly devoid of dangerous consequences. Werlholf, indeed, observes, that it has in few instances terminated fatally; but death probably occurs only where the eruption is second- ary, and associated with some other more serious malady. Richter 518 MILIARIA. says that in children the disease is sometimes accompanied with great difficulty of breathing. The sudden recession of the eruption does not appear to give rise to any unfavourable consequences. Treatment.—In the febrile variety of the disease, advantage may sometimes be obtained from an emetic of ipecacuanha. Richter states that the operation of an emetic will occasionally put a speedy stop to the progress of the disease. In general, however, one or two mild laxatives, rest, simple diet, cooling drinks, and the occasional use of the tepid bath, will be sufficient. Where there are symptoms of acidity in the primae viae, magnesia or alkaline remedies, particularly lime- water, will be proper. When the disease occurs in irritable and debilitated subjects, or in persons of weak and disordered digestive powers, benefit may be derived from moderate doses of quinine, sul- phuric acid, and the usual preparations of iron, after the alimentary canal has been evacuated by emetic and laxative remedies. Reil says, copious draughts of cold water often produce a very good effect. In the chronic variety of urticaria, particular attention should be paid to the diet; for, in some instances, it would seem to depend on some article of food rendered oppressive or irritating to the stomach by constitutional habit or idiosyncrasy. " I have," says Willan, " desired several persons affected with chronic urticaria, to omit first one, and then another article of food or drink, and have thus been frequently able to trace the cause of the symptoms. This appeared to be different in different persons. In some, it was malt liquor ; in others, spirit or spirit and water; in some, white wine ; in others, vinegar ; in some, fruit; in others, sugar ; in some, fish ; in others, unprepared vegetables." Almost all the useful diaphoretic altera- tive remedies, such as sarsaparilla, the root of burdock, the golden sulphuret of antimony, dulcamara, Lisbon diet drink, &c, have been at times recommended, but they rarely appear to afford any particular advantage. Fowler's solution, however, is a very efficacious remedy in the chronic form of the disease. It is mentioned by Cazenave as having been successfully used in a very obstinate and distressing case of this kind. Dr. Dewees has used it frequently with success, and I have myself employed it in a few obstinate cases with the happiest effect. To relieve the extreme itching, various external applications have been recommended. Vinegar and water, or lemon juice diluted with water, will sometimes procure considerable relief. The tepid bath, also, may be used as a palliative for this purpose. Sea-bathing, or washing with salt water, has been used with good effect, both as a palliative and a curative means. Dusting the affected part with rye meal or hair powder, gives some relief from the itching and tingling. Sect. IV.—Miliaria.—Miliary Fever. This is a febri'e affection, characterized by an eruption of acumi- nated vesicles, of the shape and size of millet seed, more or less thickly MILIARIA. 519 scattered over the surface of the body. These minute vesicles are at first red, and surrounded with erythematous areolae, which run into each other when the eruption is copious, and give a uniform vivid red- ness to the surface (miliaria rubra). In the course of from twenty- four to forty-eight hours, they enlarge, and the contained fluid be- comes whey-like, giving them a white or pearly appearance (miliaria alba). When the vesicles are very numerous, some of them unite, and form here and there vesicles of the size of a pea ; and on some parts they are closely grouped into irregular patches of various sizes. In a few instances, some of these confluent vesicles become filled with a purulent fluid (miliaria purulenta). In some cases the eruption retains its red colour throughout; and occasionally the vesicles are white from the commencement. The miliary eruption appears in general as a symptomatic exan- theme in various forms of fever; "in continued, remittent, inflam- matory and contagious, as well as other diseases;" and it has been much doubted whether it ever occurs as an idiopathic or independent malady. Bateman says, that " it is perhaps invariably symptomatic;" and this would seem to be the general sentiment at the present day. Cazenave, nevertheless, asserts, " that there are instances where it is idiopathic, as when it occurs in persons in good health after violent exercise during the heat of the summer;" and Richter expresses the same opinion. The appearance of the eruption is almost always preceded by pre- monitory symptoms ; such as a sense of anxiety in the epigastrium ; weight and oppression in the breast, accompanied with a short dry cough ; pains in the loins and extremities; a benumbed prickling sen- sation in the fingers; stinging, itching, and burning pain in the skin; a small, frequent, contracted and tense pulse ; cephalalgia; vertigo ; ringing in the ears ; and a feeling of heaviness in the head ; creeping chills; disposition to syncope; palpitation; twitching of the tendons; delirium. The most characteristic phenomenon, however, is the pro- fuse, sour, rank sweat, which is said almost invariably to occur just before and during the appearance of eruption. Sometimes, however, the miliary vesicles come out without any precursory symptoms what- ever.* The eruption always appears first on the neck, breast, and on the inner surface of the arms; and then successively on the abdomen, back, and inferior extremities. The duration of the eruption is very variable. In some instances it disappears as early as the fifth or sixth day; but in the majority of cases desquamation does not take place until the ninth or tenth day, and occasionally not until a still later period. Not unfrequently the eruption of vesicles is repeated twice, thrice, and even a fourth time, so as to protract the whole course of the disease to the sixth or seventh week. In most instances new vesicles appear daily for five or six days, and longer. This eruption appears to be peculiarly liable to recede from the slightest causes; and the consequences of a sudden retrocession are often extremely alarm- ing. Great anxiety in the praecordial region ; extreme restlessness ; * Richter, Specielle Therapie, bd. ii, p. 541. 520 MILIARIA. increased febrile irritation; violent delirium; coma, or strong pulmonary congestion, with distressing dyspnoea, are among the consequences which are apt to result from this accident. If under these symptoms the eruption do not reappear, or copious diarrhoea, or some other eva- cuation, do not ensue, a fatal termination will be almost inevitable. (Richter.) This eruption does not appear to be the effect of critical effort in the system, or in any degree to diminish the general symptoms, if we except those miliary vesicles which sometimes occur towards the termination of rheumatic fever and gout.* Causes.—That the miliary eruption is, generally, an artificial dis- ease, has been long ago fully established. In the latter part of the seventeenth, and the commencement of the eighteenth century, when the alexipharmic, or heating and sweating plan of treatment was so much in vogue on the continent, miliary fevers of the most fatal character were among the most frequent diseases. As soon as the antiphlogistic and cooling method of treating febrile affections became more universally adopted, the miliary disease was but rarely ob- served ; and it is now almost an unknown affection, except in its mildest form. By a stimulating, sweating, and heating treatment, miliary vesicles may be produced in every variety of febrile disease; and as such a plan of treatment is peculiarly apt to render even mild and manageable fevers dangerous and malignant, we may readily conceive how fatal the diseases must have been which were thus fomented into the miliary eruption. Sometimes, however, miliary vesicles make their appearance in acute diseases under the best regu- lated antiphlogistic treatment; and there can, I think, exist but little doubt that an eruption of this kind appears at times as an idiopathic disease. I have seen but few instances of this kind; but one case vvhich came under my notice within the present year, was apparently of this nature. The patient, a child, complained for a few days of slight indisposition, which was followed by an eruption of innumerable red points or vesicles. On the second day they became more distinctly vesicular and whitish, and continued until the fourth day before desquamation began. There was throughout the disease a constant moderate perspiration. Cazenave and Schedel observe, that, " in certain cases of violent entero-colitis, accompanied with general debility, the miliary erup- tions, which often occur at night during the paroxysms, present the next day a complete vesicular appearance, and the portion of skin which they cover, is destitute of redness, and appears as if a mul- titude of minute drops of limpid water had been sprinkled over its surface." The affections in which the miliary eruption is most apt to occur, are : puerperal fever; gastro-intestinal irritation or inflammation ; inflammation of the serous membranes; rheumatism; and Richter says that females affected with severe leucorrhoea are particularly liable to this affection on the occurrence of febrile irritation. The * Stoerk, Barretta, Dissert, de Miliaris Natura, &c, as quoted by Richter. LICHEN. 521 occurrence of this eruption is said to be favoured by a confined and damp atmosphere; excessive sanguineous and mucous discharges; insufficient and innutritions diet; acid and other irritating substances in the alimentary canal; and intemperance. Treatment.—The attending fever must be treated according to its character and symptoms, without any regard to the miliary exan- theme. In general the febrile irritation is sthenic, and requires an antiphlogistic treatment, and cooling regimen. In short, where the eruption is symptomatic, we must prescribe for the original malady, and not for the cutaneous affection. The idiopathic cases are mild, and require little more than gentle aperients, cooling drinks, and free ventilation, without, however, exposing the patient to a cold or humid air. The diet, of course, must be mild and unirritating; and in instances which manifest much gastric derangement, a gentle ipecacuanha emetic may be given with advantage. When the eruption recedes, and unfavourable symptoms ensue, we should endeavour to recall it to the surface by warm bathing and mild diaphoretics—such as Dover's powder ; and where the arterial action is low, by the inter- nal use of carbonate of ammonia, infusion of serpentaria, camphor, and opiates. Sect. V.—Lichen. This affection is characterized by minute firm elevations or pim- ples, (papulae,) generally appearing in clusters, usually of a white colour, sometimes red, and attended with considerable itching. Sys- tematic writers describe many varieties of the disease. Lichen simplex.—This disease almost invariably commences with transient flushes of heat in the face ; lassitude ; a slightly accelerated pulse, and occasionally severe headache ; weakness; painful sensa- tions in the stomach, and general febrile irritation. The eruption consists of red and inflamed miliary pimples, attended with heat and itching. In three or four days the redness begins to fade, and on the following day desquamation commences, which is usually completed in three or four days more, unless successive crops of papulae appear, which sometimes occurs. In the chronic variety of simple lichen, the pimples are usually white, and but slightly or not at all inflamed. The eruption is preceded by moderate itching. The papulae are seldom very perceptible, but in passing the hand over the skin it receives the sensation of a slight roughness from the small firm ele- vations on the surface. Its course is tedious, and of uncertain dura- ration, lasting often several months. The skin becomes thickened, and at last exfoliates in large scales. Jlcute lichen occurs most com- monly on the face and body ; the chronic, on the extremities, more especially on the back of the hands. In irritable habits it sometimes returns every summer. Persons subject to gastric pains and headache, are sometimes affected with this eruption; as if by crisis, when these affections go off. (Bateman.) 522 LICHEN. Sometimes the pimples occupy the roots of the hairs of the skin. (L. pilaris.) And in this case the disease generally continues long. In some instances the papulae appear in patches or groups, well defined, and approaching to the circular form. (L. circumscripta.) These spread at the same time that the central part heals and exfoliates, remaining, however, slightly red and scurfy. Occasionally the patches are livid, the pimples being soft and flat. (L. lividus.) These are sometimes mixed with dark red or purple maculae from sanguineous extravasation, occurring most commonly on the lower extremities of relaxed debilitated subjects. The eruption is sometimes disposed into the form of a long stripe or band, extending in a spiral manner round an extremity. (L. gyratus, Biett, Cazenave.) At times the eruption consists of larger pimples than the usual size. (L. urticatus.) They are inflamed, prominent, large, confluent, "and resemble the stings of a nettle." They come out suddenly on the face or neck, particu- larly in young persons and females in the summer. A burning pain and considerable itching attend. They usually disappear in a short time, but often return at irregular intervals. (Cazenave and Schedel.) Infants at the breast are subject to a modification of this eruption, (L. strophulus,) in which the papulae are "either redder or whiter than the skin, and attended with great itching, which is much in- creased by the heat of the bed." It is acute in its character, and subject to distinct exacerbations. (Cazenave.) Lichen agrius.— This is conspicuously febrile; the eruption con- sists of a multitude of vividly red miliary pimples, aggregated into large patches, seated on a diffused erythematous surface. Itching, heat, and a sense of painful tingling, greatly increased by the heat of the bed, by active exercise, and stimulating ingesta, are experienced. Morning remissions and evening exacerbations occur. The skin around the patches is generally painful and somewhat swollen. The eruption and general symptoms usually increase until about the fourth or fifth day, when small ulcerations appear on the summit of the pimples, discharging a sero-purulent fluid, which concretes into small, yellow, prominent crusts. These finally fall off, and are suc- ceeded by thin scales. The disease usually continues from twelve to fifteen days. The itching and stinging sensation in this variety of the disease is often extremely violent. In many instances the eruption appears and disappears several times before it finally goes off. The skin of the affected parts generally, at last, become harsh, chappy, and extremely painful when rubbed. This variety may terminate in impetigo, a chronic pustular affection. (Bateman.) When the eruption recedes, from exposure to cold, it is apt to be followed by an increase- of fever, headache, vomiting, and colic pains. Simple lichen may asume this form of the disease. L. agrius is most apt to occur in young persons of vigorous and sanguineous habits. (Cazenave.) Lichen may also acquire a chronic character. In this case the cuti- cle becomes harsh, hard, full of fissures, dry and rough, particularly in the hollow of the articulations. Causes.—Lichen occurs in persons of all ages, and in both sexes. Summer and spring are the seasons more favourable to its occurrence. LICHEN. 523 High temperature, particularly the heat of the sun, is apt to excite it. Mental affections, stimulating potations habitually indulged in, gastro- intestinal irritation, and internal inflammations, are mentioned among its most obvious causes. Diagnosis.—Simple lichen may be distinguished from eczema by its acuminated, solid, and very prurient pimples; the eruption of eczema consisting of transparent vesicles, attended only with slight smarting pain. From scabies, lichen may be known by the distinct vesicular character of the former, and its usual location on the bends of the joints and between the fingers. The vesicles of lichen are aggregated in clusters. From prurigo, lichen is distinguished by the flat, irregular appearance of the papulae in the former, and their being usually lacerated, and covered with small blackish crusts. The itch- ing and burning of prurigo are always extremely distressing; in simple lichen it is generally slight. (Cazenave.) Lichen circumscriptus sometimes resembles herpes circinatus; but may be known from it by the red, or more strongly inflamed state of the skin surrounding the margin of the latter, and the distinct papular character of the former, both in the centre and at the border of the patches ; whilst in herpes the central disk is free from vesicles. Lichen urticatus may be mistaken for erythema papulatum, or syphilitic lichen. The diagnosis between them consists in the large size of the erythematous patches, their pale red colour, the almost entire absence of itching, the less prominence, and their not appearing and disappearing several times in succession. The copper colour of the papulae of syphilitic lichen, their freedom from inflammation and much itching, and their slow progress and long continuance, distinguish it from L. urticatus. From chronic eczema lichen agrius is often not easily distinguished. The presence of lichen, however, may be known by the great itching, roughness'and thickening of the skin, and the appearance here and there of distinct pimples. Prognosis.—Lichen is never a dangerous, but. sometimes an ex- tremely troublesome and disagreeable affection. The precursory fever is seldom so great as to keep the patient confined, and in the majority of instances it is wholly absent. By violent friction and scratching, and sometimes spontaneously, severe excoriations and burning pain occasionally occur, which are almost always difficult to remove. When the eruption is repelled by improper applications, or by other injurious influences, as cold, severe fever, internal inflammations, great heat, thirst, fixed pains in the abdomen, vomiting, &c, sometimes ensue. Treatment.—In the simple variety, tepid bathing; mild aperients; diluent acidulated drinks; abstinence from heating drinks, food, and exercise, are all that is necessary to prescribe. Dry, irritating appli- cations are improper—particularly sulphur, and the metallic oxides. To relieve the severe itching and burning in the affected parts, we may apply cream or wash the part with flaxseed tea, or some other mucilaginous fluid. When the aflected parts become very red and irritated, attended with constant stinging pain and itching, a laxative dose of calomel maybe given occasionally, and fresh, unsalted butter 524 ECZEMA. applied. In the chronic forms of the disease, alkaline and sulphur- ous baths, mild laxatives,* tepid bathing, at first with the water of scalded bran, " and afterwards with water rendered alkaline by adding subcarbonate of potash, in the proportion of half an ounce or an ounce to four or five pounds of water. Cazenave advises, in severe cases of this kind, anointing the eruption with one of the following ointments.! During desquamation, the internal use of the diluted sulphuric acid is often beneficial. The treatment must be more active, however, in lichen agrius. Here sanguineous evacuations, both topical and general, are often necessary in the beginning of the complaint; but when blood is drawn by topical means, it must be taken from a sound part of the skin. (Cazenave.) Low diet, laxatives, diluted nitric or sulphuric acid taken internally, laxative doses of calomel, alkaline sulphurous baths in the decline of the malady, the internal use of Fowler's, solu- tion, with a gradual increase of the dose, until it produces gastric disturbance, are the means generally relied on in cases of this kind. Sect. VI.—Eczema. Eczema is a vesicular eruption, which occurs both in an acute and chronic form. Cazenave and Schedel divide acute eczema into three varieties, namely E. simplex, E. rubrum, and E. impetiginodes. 1. E. simplex.—The eruption consists of innumerable small, closely approximated, transparent vesicles, without any surrounding inflammation, distributed over a greater or less extent of the surface —the skin everywhere retaining its natural colour. No premoni- tory symptoms, but only a slight itching, precedes the eruption. The fluid in the vesicles soon becomes opaque, and after a short period is absorbed ; the vesicles then shrivel, and the cuticle desquamates slowly. It never spontaneously gives rise to inflamed surfaces. This eruption is usually local, or confined to certain parts, commonly the arms and between the fingers, and being attended with severe pruritus, may be mistaken for the itch. Heating and irritating appli- cations to the skin often produce this affection. " It often appears between the fingers of women in child-bed;" and in persons who are much exposed to the heat of a fire. It is sometimes associated * R.—Calomel gr. xii. Hydrarg. sulphur, nigr. gr. xxxvi.—M. Divide into 12 equal parts. S. Give one every other evening to a child of from 2 to 7 years old, with a small dose of ol. ricini on the following morning. t R.—Calomel 3ss. P. camph. gr. xii. Axungise §i.—M. f. Or— R.—Protoioduret hydrarg. gr. xuto ^i. Axungiae gi.—M. f. ECZEMA. 525 1 with itch, and appears to be excited by the irritating remedies usually ■' employed for the cure of that affection. 2. Eczema rubrum.—Heat, stiffness, and some tingling in the skin, precede the eruption in this variety. The affected surface is inflamed and vividly red, covered with very minute acuminated pimples of a shining white or pearly hue. After some time, vesicles of the size of a pin's head, surrounded with distinct red areolae, ap- pear on the affected parts. In the course of six or seven days, the contained fluid is absorbed, the vesicles shrivel and desquamate, leav-- ing a pale red surface, sprinkled with minute rounded papulae, each rising from a small whitish disk. In some instances the cutaneous inflammation increases, and continues beyond its ordinary duration; the vesicles become confluent, break, and discharge an irritating fluid which causes superficial excoriations ; and at last, concrete into large thin, pliant scales, leaving inflamed surfaces on falling off. 3. Eczema impetiginodes.—Violent inflammation, swelling of the affected parts, and vesicles generally congregated or confluent, filled with a sero-purulent fluid, are the principal characteristics of this variety of the disease. These purulent vesicles soon break, and the fluid concretes into soft, yellowish, and often extensive scales, or thin crusts. When these fall off, they leave red surfaces, exuding a red- dish fluid, which dries into thin laminae. The eruption is commonly » confined to a particular part, or even a single spot. Occasionally, however, it occurs over the whole body, and is attended with con- siderable fever. The disease may continue from ten to twenty days, and upwards. The vesicles are generally transparent at first, and become pustular afterwards. This variety also sometimes assumes a chronic character, resembling then the chronic state of eczema rubrum. 4. Chronic eczema.—When acute eczema is very severe, it often terminates in chronic excoriations and fissures of the skin on different parts of the body, particularly in the bends of the knees and elbows, and about the axillae. The parts thus irritated and inflamed, exude an abundance of serous fluid, which causes the linen to adhere to them. In this state it usually remains for several months, the dis- charge continuing undiminished. In some instances, the exuded serum dries into soft, yellowish, and thin crusts, leaving an inflamed and nearly dry surface when they fall off. " These crusts form at greater intervals; they become drier, and the disease seems on the point of disappearing, when, on a sudden, and without any assigna- ble cause, the inflammation acquires greater intensity." New vesi- cles arise which, like the former, soon break and discharge their fluid; " and the affection goes through the same course, and the disease may thus last for years." (Cazenave.) Sometimes the thickened, red, fissured skin, remains dry, and the crusts are drier, more firmly attached, and of a brownish-yellow hue, leaving but a slightly red surface when they separate. Occasionally, indeed, the skin for a long time remains vividly red, cracked, with dry scales of altered cuticle thinly scattered over the surface. Chronic eczema commences on a limited portion of the skin, often not above a few inches in diameter, and spreads afterwards over a greater or less extent of the surface. 526 ECZEMA. The itching is always very great, and returns by spells, causing an irresistible desire to scratch. The parts furnished with hair, the region of the pubis, the armpits, groin, scrotum, pudendum, and the bends of the joints, are most apt to become the seat of eczema, although every part of the body may become affected with it. Causes.—Though not contagious, yet instances do occasionally occur in which this disease is communicated from one to another by protracted contact. (Biett, Cazenave.) It occurs more frequently in women than in men, and in the warm than the cold seasons. Its general cause is unknown. It may be excited by direct irritating applications to the skin, as a blister, sinapisms, turpentine, valerian root, the rays of the sun,* dry frictions, and irritating ointments, lime and sugar.t The use of mercury, when long continued, sometimes produces a very severe variety of eczema. Diagnosis.—Simple eczema often greatly resembles itch. They may be distinguished by .the following circumstances. In eczema, the vesicles are flat or rounded; in itch, pointed; in the former they are nearly or entirely in contact with each other; in the latter they are single, and considerably separated. The itching of eczema is at- tended with smarting pain ; in itch, the pruritus " is rather agreeable than painful." The impetiginode variety of eczema has been confounded with impetigo. The former, however, occupies large spaces, the latter usually small ones. The eruption in impetigo is strictly pustular from the beginning. In eczema impetiginodes, it is vesicular at first, the vesicles being generally transparent, and never contain genuine pus, as they do in impetigo. In the latter, desiccation gives rise to thick, yellowish, uneven scabs; in eczema, only thin pliant scales are formed. Vesicles of eczema rubrum surround the latter, but they never appear in impetigo. Chronic eczema is very liable to be confounded with lichen and psoriasis. Lichen agrius, the variety most apt to be mistaken for chronic eczema, differs from this affection in the thick, small, and yellow appearances of the scales or scabs, and the papular appear- ance of the surface which they leave on falling off; whereas, the surfaces left by the separation of the thin lamina in eczema, are smooth, red, often shining, and generally slightly excoriated. In lichen, small hard papillae may be seen around the eruption; in eczema, vesicles only appear in the neighbourhood of the eruption. Treatment.—Diluents, acidulated with sulphuric or nitric acid; a light and simple diet; occasional tepid bathing; gentle laxatives; and where the eruption is extensive, alkaline and sulphurous baths,! with * The prickly-heat or heat spots are classed with this variety of eruptions. (Willan.) t Persons who are in the habit of handling or working in sugar are liable to an eruption of this kind on the hands, called the grocers' itch. (Bateman.) And brick- layers are subject to a simdar affection from the irritation of lime. X The alkaline bath is made by dissolving five or six ounces, or more, of the ECZEMA. 527 some of the milder vegetable tonics, such as infusions of cinchona, serpentaria, or colomba when languor or debility exists, are the principal useful measures in this variety of the complaint. When the eruption continues long, advantage may be obtained from rubbing the affected parts with sulphur ointment. In eczema rubrum and impetiginodes, frequent, bathing, or emol- lient fomentations of the affected parts, will generally moderate very considerably the itching pain and tenderness of the eruption ;* emol- lient poultices also often answer well as a palliative application. After exfoliation, the following ointment may be beneficially applied to the tender and half-excoriated surfacet by means of linen rollers renewed twice daily. Mild laxatives should be regularly given ; and a simple, unirritating diet, as well as total abstinence from all kinds of stimulating drinks, enjoined. It will also be useful to administer refrigerant diaphoretics, such as sweet spirits of nitre, small portions of nitrate of potash with tart, emetic, spiritus mindereri, and to allay nervous irritation and procure rest at night, full doses of Dover's powder with a few grains of calomel in the evening. The diluted mineral acids with tonic bitter infusions will at times be proper during the subsidence of the disease. All kinds of irritating applications must be avoided. When the exciting cause is obvious, and of such a nature as to enable us to remove it, the first step in the treatment must of course be to obviate its influence. In chronic eczema, emollient baths of about the temperature of 90° Fahr.; the internal use of nitric or sulphuric acid; occasional laxatives; alkaline solutions internally, and when the itching is great, externally,^ are among the principal remedies in this form of the disease. One or two of Plummer's pills§ given twice daily, have beeri. found very useful in chronic eczema. Benefit may also be derived from laxative doses of calomel and pulvis antimonialis, with subcarbonate of potash or soda in a bath. The sulphurous bath is made by add- ing about four ounces of sulphuret of potash to a bath. (Cazenave.) * The French are in the habit of using a decoction of bran, or the water of scalded bran, for this purpose. Cazenave and Schedel recommend cataplasms made of potatoes and some emoUient decoction. t R.—Emplast. plumbi §ii. Cerae flavae §ss. Olei amygdal. dulc. Sjss.—Melt the plaster with the wax, then add the oil, and stir the mixture untd it has entirely cooled This ointment is particularly recommended by Dr. Pearson.—See Bateman's Synopsis, &c, p. 12. X " Half a drachm of the subcarbonate of potash dissolved in a pint of infusion of chicory may be given internally." Washing the affected parts with a solution of the subcarbonate of potash or soda, before going to bed, will generally afford much relief. (Cazenave.) ♦ B..—Calomel. Antimon. sulph. praecipitat., aa 311. Pulv. g. guaiac. 31V. Sapo. venet. 3d. Mf. pi., aa gr. iii. 528 ECZEMA. an occasional dose of sulphate of magnesia or soda. Sulphurous waters, employed both externally and internally, will, in general, contribute materially towards the removal of the disease. Infusions of sarsaparilla, chimaphila, or of the slippery-elm bark, with small portions of antimony, may also be usefully employed. In a very severe and inveterate case of chronic eczema, I prescribed the follow- ing pills, in conjunction with sarsaparilla syrup, with complete suc- cess.* In the dry, scaly, cracked form of local eczema, " as it occurs in the hands," Cazenave recommends frictions on the part, with an ointment made by mixing half a drachm of proto-nitrate of mercury with an ounce of lard ; or of twenty grains of proto-ioduret of mer- cury rubbed up with an ounce of axunge. I have known a case of this kind cured by the following application^ first recommended, I believe, by Alyon. (Essai sur les Proprietis M6d. de VOxygene.) Washing the affected parts with an infusion of stramonium leaves, or of solanum nigrum, or hyoscyamus, will generally greatly allay % the itching and painful irritation. When the eruption is confined to a limited surface, solutions of borax, lime-water and milk, or an ointment made by mixing half a drachm of calomel with an ounce of lard, may be occasionally applied with benefit. The best local application, according to my own experience, however, is stramo- nium ointment intimately mixed with a portion of calomel, in the proportion of thirty grains of the latter to an ounce of the former. The tincture of cantharides is sometimes very efficacious in obstinate cases of this affection. Cazenave states that it is particularly useful in the eczema of women.J Arsenic also has been used with com- plete success in inveterate instances of chronic eczema. (Biett, Caze- nave.) The Asiatic pills appear to be the best arsenical preparation in this affection. One of these should be taken daily, and continued for several months. I have employed Fowler's solution in several cases with marked advantage. * R.—Muriat. hydrar. corrosiv. gr. iii. G. opii gr. x. G. camphor, gr. xx. Conserv. rosar. q. s.—M. Divide into 40 pills. Take one every morning, noon, and evening. t R.—Axunge §viii. Melt it, then gradually add nitric acidgi, and stir until it is cold. X Cantharides have been successfully employed in various chronic cutaneous affections. Keir relates several very obstinate instances of impetiginode affections which yielded to a protracted course of this remedy (VoigteVs Arzneimittell, bd. ii, Abth. ii, s. 15). Home also gave it successfully in herpetic affections (Clinical Experiments, &c). Tilenius (uber die Flechtenart. Hautauschl., 1802), and Simons (Med. Comment., vol. i), relate instances of its successful employment in similar cases. ERYTHEMA. 529 Sect. VII.—Erythema. The term erythema is applied by Willan and other late writers, to a cutaneous affection, characterized by a slight superficial irregu- larly circumscribed redness of some portion of the skin, attended with symptoms of constitutional disorder. It is most commonly seated on the face, breast, and extremities, and continues usually from one to two weeks. It appears, generally, as a symptomatic affection— although in many instances it occurs without being preceded by any obvious constitutional symptoms. Superficial spots of a vividly red colour, variable in size, and attended usually with very slight heat and pain, come out on a greater or less extent of the surface. When these spots are pressed with the finger, the redness disappears for a moment, as in erysipelas. In some instances, not the slightest tume- faction attends ; but in others, the spots become swollen and firm to the touch. Sometimes the bright red patches are irregularly rounded, and present, on their first appearance, a slightly elevated rough or papulated surface. In a few days the redness becomes more vivid, and afterwards changes to a violet hue, particularly on the central parts of the patches. The slight swelling subsides in the course of the second day, but the redness continues from about ten to fourteen days. This variety of the disease (the E. papulatum of Willan) is most frequently met with in females and young persons, and is usually seated on the neck, breast, and arms. It is sometimes attended with much general disorder—such as anorexia; a small and frequent pulse; great depression of strength and spirits; and acute pain in the limbs^ In most instances, however, the constitutional symptoms are slight. (Bateman.) In some cases "small slightly elevated tumours are interspersed through the patches," which continue six or seven days before they disappear—the redness going on for about a week longer. (E. tuberculatum.) This eruption frequently appears also in the form of red oval spots, usually seated on the anterior part of the legs, and sometimes, though rarely, on other parts—as the chin and arms. The spots become elevated'towards the centre, and are firm and painful to the touch, presenting the appearance of slight nodes when seated on the tibia. These protuberances rise slowly, and subside about the eighth or ninth day, at the same time that their colour becomes bluish, as from a bruise. This variety of the disease is pre- ceded for four or five days by moderate fever, general uneasiness, and depression of strength. Bateman says that it seems to occur only in females; but Cazenave and Schedel state that it is met with also " in infants, and in young persons of a weak constitution and lymphatic temperament." This variety constitutes the E. nodosum of Willan. The erythematous spots which sometimes occur in acute diseases as symptomatic eruptions, (E.fugax,) are usually of short duration, and resemble the redness produced by pressure or friction. They occur also in chronic affections, "especially those in which the primae viae are deranged." Causes.—Erythema may be produced by the direct action of vol. i.—34 530 ROSEOLA. irritating agents on the skin, such as the direct rays of the sun ; acrid secretions or discharges remaining long in contact with the skin ; and by the chafing of two contiguous surfaces, as between the breasts, in the arm-pits, groin, and on the buttocks and internal parts of the thighs from riding on horseback. It occurs symptomatically from intestinal irritation, dentition, menstrual irregularities, particularly about the decline of the menses, from irritation in the stomach, and in almost every form of acute disease. It is sometimes associated in oedema, or anasarca of the legs. Diagnosis.—From erysipelas, erythema is distinguished by the limited extent of the spots; the absence of pain, of vesication, and of tumefaction; and the mild nature of the disease. From roseola it differs in its vivid redness, and in the less distinctly defined circum- ference of its spots or patches. The spots of roseola are never raised above the surrounding skin; those of erythema nodosum are. Ery- thema papulatum may be known from urticaria by the greater elevation of the latter, and the great itching which always attends, as well as by its "irregular and often rapid course." The absence of itching in erythema distinguishes it also from lichen urticatus. (Cazenave.) Treatment.—Light diet, gentle diaphoretics, the internal use of the mineral acids, laxatives, warm baths, tepid ablutions, and sooth- ing applications when it occurs from the friction of surfaces, such as aqueous solutions of borax, opium, acetate- of lead, or pulverized starch, or the powder of lycopodium, comprise all that is necessary in idiopathic erythema.* Sect. VIII.—Roseola. This affection consists of rose-coloured spots of various forms, without swelling or elevation of the skin or papulae, and is usually preceded and accompanied by febrile symptoms. These efflores- cences may occur over the whole surface of the body, but they are usually confined to one or more parts. Its course varies in dura- tion from one to about six or seven days. Sometimes the rose-red spots are nearly circular, contiguous to each other, and not above three or four lines in diameter. They are usually connected with disorder of the stomach and bowels, and occur almost exclusively in infants; and they seldom last longer than thirty-six hours. During dentition these spots are apt to assume an irregular and nearly con- fluent appearance, and generally succeed violent symptoms of gastro- intestinal disorder, such as vomiting, diarrhoea and fever. There is a variety of this eruption which has been mistaken for * To relieve the inflammation and tenderness produced by chafing, the follow- ing ointment, applied by strips of soft linen, is often promptly effectual: R.—Ungt. stramonii ^i. Pulv. lythargyri gi. Pulv. opu 388.—M. ROSEOLA. 531 measles, and which is most apt to occur in children during summer. (R. aestiva.) It commences with chills, languor, headache, followed by febrile reaction, and occasionally delirium, and even convulsions. The skin is hot and dry, the bowels are constipated or affected with diarrhoea, and the appetite wholly depressed. From the third to the seventh day after the commencement of these symptoms, the erup- tion makes its appearance, first on the face and neck, and then gradu- ally spreads over a greater or less extent of the surface of the body. The spots are usually from one to three lines in diameter, resembling the spots produced by touching bibulous paper with the point of a pen dipped in red ink. When the eruption is very copious, the spots run into each other on some parts of the body, but the roseolous points may still be distinguished on the red surface. These spots are not in the slightest degree elevated, yet when the patient has been kept too warm, or when heating diaphoretics are used, a papular eruption is apt to appear along with the roseolous spots. The erup- tion is attended with troublesome itching, and the febrile irritation continues until it disappears with the eruption. It is often attended with sore throat, or painful deglutition, but not with coryza, inflamed eyes, and cough, like measles. The spots may continue from three to ten days; they disappear without desquamation, Occasionally a second eruption occurs after the first has gone off. In some rare cases, the rosy spots assume an annular shape, the central parts retaining the natural colour of the skin. (R. annulala, Willan.) Roseola occurs most frequently in women and children, and is not contagious. It occasionally prevails epidemically, and sometimes precedes the eruption of small-pox, or it follows the vaccine affection. Dentition, and a draught of cold water when the body is heated by exercise, may give rise to this eruption; and it is often associated with gastric disorder, particularly in children. Diagnosis.—Measles and scarlet fever are the affections with which roseola is most liable to be confounded. The more distinct catarrhal character of measles, the irregular semilunar grouping of its small red points, and the vivid redness of its eruption, contrasted with the larger, more circular, well defined, and rose red spots of roseola, will generally enable us, without difficulty, to form a correct diagnosis. The small vesicular elevations, the irregularly diffused raspberry efflorescence, and the tumefaction of scarlatina, are usually sufficient to distinguish this affection from roseola. Roseola is not contagious; measles and scarlatina are. Prognosis.—This disease is almost always wholly free from dan- ger. Heim,* Selle,t and Formey,t however, mention the occurrence of very violent and fatal epidemics of this kind. But in these the eruption was probably purely symptomatic of typhus fever. Hildebrandt refers to an exantheme, somewhat similar to this one, as a very constant, * Bemerk, uber die Verschieden. des Sharlachs, der Roethel und der Masern. t Neue Beitrage zur natur-und Arzneiwissenschaft, tem. i. X Topographie von Berlin, Richter, Specielle Therapie, bd. ii, p. 524. 532 PURPURA. though transient, symptom, in the stage of excitement of contagious typhus. Treatment.—Rest, mild aperients, acidulated cooling diluents, a simple and irritating diet,an equable and moderate temperature; and where the temperature of the skin is elevated, refrigerant diaphoretics, are, in general, all that is required in the treatment of this affection. When internal inflammations occur, a more vigorous and appropriate course will be demanded. Sect. IX.—Purpura. Hemorrhcea Pelechialis, Ecchymome, Hemacelenose. This affection is characterized by spots or patches of a vivid red, inclining sometimes to a purple hue, varying in size from a line to several inches in diameter, and retaining their colour under pressure. These maculae appear often without any perceptible febrile pheno- mena whatever; but they occur also in the latter stage of malignant fevers, (petechise,) and in this case are always of the most fatal im- port. Willan has divided purpura into five species: purpura sim- plex; purpura hemorrhagica; purpura urticans; purpura senilis; and purpura contagiosa. Simple purpura consists in small bright red patches, appearing usually on the extremities in a successive manner, preceded com- monly with slight restlessness, nausea, headache, languor, and want of appetite, but without any obvious irritation of the circulatory sys- tem. The duration of this affection is almost always tedious, and varies from a few weeks to many months. The individual spots, however, do not often continue for more than seven or eight days— the whole course of the malady being made up either by a continuous succession of the eruption, or a succession of eruptions, with short intervening periods. This variety of the disease occurs usually in young subjects, and appears equally liable to attack vigorous, sanguineous, and robust, as well as feeble, relaxed, and delicate individuals. It is said to appear more frequently during warm and dry weather, than in the cold sea- sons. Its diagnosis is not difficult. The persistence of the redness when pressed with the finger, is alone sufficient to distinguish it from all other similar affections. Simple purpura is always a mild affection, and though sometimes very prolonged in its course, can never be re- garded as dangerous. P. Hemorrhagica.—The variety of purpura, however, which has attracted the most attention, and which, indeed, is always a very seri- ous and alarming affection, is the purpura hemorrhagica—or mor- bus maculosus haemorrhagicus of Werlholf. The spots in this variety are generally numerous, and of a dark red colour, with here and there irregular livid patches resembling recent bruises. They usually ap- pear first on the legs, then on the arms, and lastly on the body; the hands almost invariably remaining free from them. In some instances PURPURA. 533 the cuticle over these maculae becomes slightly elevated, with a small portion of bloody serum underneath.* These spots occur also on the mucous surfaces, particularly in the mouth, nostrils, rectum,or vagina, giving rise to hemorrhages, sometimes so copious as to cause speedy death. In general, however, the hemorrhage is moderate, returning at intervals, and either ceases spontaneously, or recurs again and again until the system is exhausted, and a fatal termination occurs; sometimes a slight but uninterrupted discharge takes place. The constitutional symptoms vary exceedingly in this affection. Some cases commence with wandering and vague pains, lassitude, restless- ness, and exhaustion; others are not preceded by any symptoms of general indisposition. In general, however, the disease, when once developed, is accompanied with a state of depression and languor; yet in relation to the activity of the pulse, the greatest diversity occurs in different cases. In some instances it is feeble, soft, and moderately full; in others it is contracted, firm, and very frequent; and in others, again, active, full and resisting. The skin is sometimes above the natural temperature,! though generally it is cool and pale. Cough, pain in the chest, and slight oppression of respiration, fre- quently precede and accompany the cutaneous and hemorrhagic affections. Dr. Fairbairn relates a case attended with deep-seated pain in the left breast, increased on coughing, and deep inspiration, laborious breathing, and flushed countenance. Dark, venous blood oozed from the gums, cavity of the mouth, and apparently from the mucous membrane of the bronchiae; and numerous petechiae or purple spots appeared on the arms, neck, and trunk, f; Uneasiness in the stomach with abdominal pain, or tension and weight in the hypo- chondria, sometimes precede the appearance of the spots. When the disease becomes protracted, more or less anasarcous tumefaction of the legs and face, emaciation, and great weakness and languor super- vene. The duration of this malady is as various as the general phenomena which accompany it. It may terminate either in health or in death, within a few days from its commencement, or run a tedious course of many months. The fatal termination of this affec- tion is frequently the immediate consequence of profuse hemorrhage from some internal organ. Cazenave states that he has -'seen patients suddenly expire from copious haemoptysis, as well as from haemate- mesis and intestinal hemorrhage." The spots or maculae are caused by the extravasation of blood under the cuticle. Concerning the etiology and pathological character of this remark- able affection, we know, as yet, but little that is satisfactory. Dr. Parry regarded the disease as being decidedly phlogistic, whilst most other writers ascribe it to an opposite character. ' It is certain, that notwithstanding the extraordinary tendency to haemorrhage—appa- rently of the passive kind—the blood drawn with the lancet some- * I. G. Arcel, (C. Zetterstrom,) Diss, de Haemorrhcea. Upsal, 1797. t See Dr. Gardiner's case—Edinburgh -Med. Chir. Transact., vol. i, p. 671. Also, Dr. Fairbairn"s case, quoted below. X Transact. Med. Chir. Society of Edinburgh, vol. ii, art. 1. 534 PURPURA. times coagulates strongly, and exhibits a sizy, and even a cupped and buffy surface.* It is equally ascertained that extensive internal inflammations are sometimes connected with this malady. In the case reported by Dr. Chambers, (Med. and Phys. Journ., Nov., 1S26), "the convolutions of the small intestines were found agglutinated by adhesive inflammation, and the whole arachnoid membrane on the upper part of both hemispheres was covered with lamina of coagu- lated lymph." More commonly, however, the blood taken by vene- section presents none of the appearances indicative of a phlogistic condition. " In many persons who were examined after death in the hospital St. Louis," says Canezave, " the blood was found in a state of remarkable fluidity." In Dr. Fairbairn's case, the blood coagulated " into a soft and tremulous mass;" and in the case reported by Dr. Gardiner, the first blood drawn coagulated imperfectly, and on the following day resembled a tremulous jelly, with a greenish surface interspersed with brownish spots. What was discharged afterwards " was more like turbid lymph, or a fluid in which some reddish colouring matter was suspended." In the majority of instances, marks of violent venous congestion,? with copious extravasation of bloody serum or dark liquid blood into the internal cavities, are detected on post-mortem examination. Pete- chiae, too, are often met with on the internal surfaces, particularly on the mucous membrane of the lungs, intestines, stomach, (Fairbairn, loc. cit.,) and fauces. In some instances almost the whole capillary system takes on the hemorrhagic action—every structure, whether membranous or parenchymatous, presenting marks of sanguineous extravasation. Under all this perplexing contrariety of phenomena, our reasonings and conclusions respecting the fundamental pathological character of this affection must necessarily be vague and unsatisfactory. That it is not essentially an inflammatory disease, though often connected with local inflammation and an active state of the circulation, appears, I think, extremely probable. It is indeed true, that in some of the most violent forms of inflammatory fever, colliquative hemorrhages and subcutaneous extravasations of blood occur; but these do not supervene until the general powers are prostrated, or a state of collapse is induced by the previous excessive excitement. In purpura, however, the pete- chias and sanguineous discharges are sometimes among the first signs of indisposition; and are but very rarely preceded by symptoms of strong vascular or phlogistic action. Dr. Stocker thinks that this affection is attended with an altered and unhealthy state of the blood, "either from want of due preparation of the fluid at the two chief sources of supply, * Dr. Stocker, Pathological Observations, &c. part i, p. 36. Parry's Posthumous Works, vol. i, p. 220. See also Dr. Chambers's case.—Med. Chir. Rev., Jan. 1827, p. 201. t The lungs are sometimes greatly engorged with sanguineous extravasation and congestion. M. Biett saw an instance of violent venous congestion of the tongue. It was of a deep livid colour, and double its natural size. (Cazenave and Schedel.) PURPURA. 535 and of the subsequent changes these fluids should undergo in their passage through the pulmonary, sanguiferous, and hepatic systems, or from the injurious effects of diseased functions in the organs of sanguification."* That a dyscrasy of the blood exists in this disease is, indeed, not at all improbable; but whether this condition of the blood has a direct and principal agency in the production of the cha- racteristic phenomena of petechiae and hemorrhage, or whether it is only one of the ultimate consequences of the primary and essential disease, is altogether uncertain. To me it seems probable that this affection has a considerable latent period before it manifests itself by external symptoms ; that primary disorder of the assimilating func- tions deranges the healthy constitution of the blood ; and finally, that the blood, deteriorated or changed, being no longer possessed of its healthy relations with the organic sensibility of the capillary vessels, causes these to suffer its ready transmission and extravasation. Treatment.—The uncertainty which exists in relation to the pa- thology of this disease, leaves us of course in an equally unsettled state with regard to the principles of its remedial management. The most opposite plans of treatment have been recommended, and prac- tised, too, with occasional success. It would seem even that the existing symptoms are often a very fallacious guide; for in some cases marked with all the usual symptoms of general debility, relax- ation, and asthenia, the use of tonic and other invigorating means has almost immediately aggravated the disease. Nevertheless, where the disease occurs in old persons or children, enfeebled by previous diseases, privations or other debilitating influences, a mode- rate tonic and exciting plan of treatment, with an invigorating regi- men, has been found most beneficial. Decoctions of cinchonia, serpentaria, or rhatany; the ferruginous preparations; mineral acids, particularly the sulphuric; wine, and a nourishing diet, may be em- ployed in cases of this kind. The only instance of this disease which has come under my notice, was in a child about seven years old. In this case I employed the nitrate of silver, in quarter grain doses, every six hours, together with from fifteen to twenty drops of the spirit of turpentine with complete success. The case continued for nearly three weeks before it yielded to this treatment. When the disease appears in adults of good and sanguineous constitutions, and who have not been previously subjected to the influence of enervating causes, tonics and exciting remedies almost invariably do great mischief. In all instances in which there are manifestations of strong visceral congestions, or of inflammation; where there is pain in the chest, in the epigastrium, hypochondria, or the abdomen; where there are evidences of intestinal irritation, or constipation exists; where the pulse is firm, corded, or tense, anti- phlogistic measures should be adopted. Bleeding is recommended by Parry, and cases have been reported illustrative of its occasional beneficial effects. A case is reported as having occurred in Bartho- lomew's Hospital which strikingly illustrates the occasional usefulness f Loc. cit., p. 40. 536 PUKPUKA. f wnnfl letting in this affection. The whole surface of the body Is'TprirTS^ver with purple spots. The gums -ere spongy livid and bloody. « The whole tongue, also, was livid, and half of it presented the appearance of a large, black, bleeding fungus, shoot- ing from its surface." Nothing but blood passed by stool. The pa- tient nevertheless felt strong, and had a good appetite. Dr. Latham drew fifteen ounces of blood, which was very buffy, enjoined water gruel, and administered mercurial purges. The patient, under this management, gradually recovered.* Where the disease is attended with an active state of the circulation or with symptoms of visceral congestion or inflammation, bleeding may be practised with a prospect of advantage. It is a measure however, which requires cautious employment even where it seems to be most clearly indicated ; for the natural tendency of the disease to exhaustion and prostration is always great, and may readily be injuriously promoted by incautious abstractions of blood. Whatever may be thought of blood-letting, almost all writers agree in recommending purgatives in this affection. Dr. Harty states, that after he had failed in one case by tonic remedies and a nourishing diet, he resorted to the free administration of purgatives in upwards of a dozen cases, and he avers, with uniform success, (Bateman.) He gave active doses of calomel and jalap daily. Of late years the oil of turpentine, in purgative doses, has been strongly recommended as a remedy in purpura. Dr. Whitlock Nicholl has reported three cases in which this article was administered with the most satisfactory result.t To a child only two years old he gave half a drachm of the oil with some syrup and water, thrice daily, for ten days in succession. Under this remedy, the disease, though very violent, gradually yielded. Cinchona was at the same time, freely used. Dr. E. Thompson also gave small doses of turpentine and castor oil with complete success.^ Dr. Belcher used turpentine ene- mata with manifest advantage.§ The turpentine, with castor oil, generally causes large, unnatural, and very fetid alvine discharges; and if the system is, at the same time, supported by tonic infusions, generous wine, and the mineral acids, nothing need be apprehended from the exhausting effects of daily purging with this mixture. According to the report of Cazenave and Schedel, the treatment usually adopted in the management of this disease by M. Biett, con- sists in the employment of acidulated drinks and laxatives; and in cases attended with much feebleness and exhaustion, the extract of rhatany, (in doses varying from a scruple to a drachm daily,) mixed with ice. This treatment is also recommended by other eminent French practitioners. (Dr. Brachet, of Lyons.)|| Local applications have been recommended to restrain the hemor- rhages, but these rarely afford any other than very temporary advan- * Med. Chir. Rev., May, 1828. t Lond. Med. Repository, July, 1821.—Ibid., No VI t Ibid., No. CXIX. f Med.'and Phys. Journ., March 1825 II Cazenave. &c, Synopsis, p. 379. ; maictl> I825" HEMORRHAGES. 537 tages. Upon the whole, therefore, moderate blood-letting, where there are strong congestions, or an active pulse, purgatives freely and almost daily employed, together with cinchona, rhatany, tinct. cinnamon,* wine, beverages acidulated with sulphuric acid, and a nourishing: diet, constitute the- means which experience has found most apt to afford relief in this affection. Advantage might perhaps be obtained from bathing the body in a decoction of oak bark or cin- chona, or water strongly impregnated with salt. CHAPTER XIX. VASCULAR IRRITATIONS WITH A FLOW OF BLOOD. Hemorrhages. Spontaneous hemorrhage may be defined, a disordered state of the vital properties of a greater or less extent of the capillary system, manifesting itself by sanguineous effusion or extravasation.t It was formerly supposed that hemorrhages depend invariably on rupture of a blood-vessel; and this opinion is, indeed, still entertained by some pathologists. Dr. Gregory seems to take it for granted that actual rupture of a vessel takes place in all hemorrhagic effusions.^ That this may sometimes occur, cannot be doubted ; but this is probably so seldom the case, as to form but a very limited exception to the general fact, that the effusions of this kind depend on a sort of sanguineous exudation, without rupture or structural lesion of the vessels. In what manner, or through what particular openings, the blood is suf- fered to escape from its proper vessels, is, however, still a matter of conjecture, or at best of uncertainty. According to Bichat, the blood is discharged through the exhalents; and Reil supposes that it trans- udes through the coats of the vascular extremities, (per diapedesin,) from deficient vital power in these structures, just as we sometimes find the bile percolated through the cystic coats on post-mortem exa- mination, or by what Dutrochete calls exosmos, through the agency of animal galvanism. When we take into view the results of some late physiological experiments, which go to show that the veins im- bibe fluids into their cavities apparently through the insensible pores of their coats, it does not appear extravagant to suppose, that under particular circumstances, they may also give exit to their contents through the same channels. It is nevertheless most probable that * Jahn. Klinik der Chron. Krank., bd. p. 308. t Bichat, General Anatomy, vol, ii. Reil, Fieberlehre, bd. iii, p. 23. X Elements of the Theory and Practice of Medicine, vol. i; p. 517. Second American edition. 538 hemorrhages. the effusion occurs, (per anastomosin,) through the exhalents, in the manner so ingeniously explained by Bichat. In consequence of a morbid change in the activity of. the sanguineous capillaries, as well as in the specific sensibility of the serous exhalents, the blood passes from the former to the latter, and by these is suffered to escape ex- ternally. Whatever doubts and exceptions may have been expressed by some recent physiologists with regard to the agency of what this eminent writer terms organic sensibility in the development of dis- eases, there is much foundation for believing that this pathological principle lies at the root of many of the morbid phenomena of the capillary system. It would be foreign, however, to the scope of this work, to enter into a particular discussion on this head. Those who may desire to obtain a full view of the facts and arguments that may be. adduced in support of this pathology of hemorrhages, may consult the chapters on thecapiUary and exhalent systems in Bichat's General tenotomy. Pathologists have divided hemorrhages into active and passive. A hemorrhage is said to be active when there is a preternatural flow of blood to the part, attended with an increased vascular excitement. In many cases, the whole circulatory system is in a state of increased activity ; but the local vascular excitement often approaches, and in- deed actually rises to the grade of inflammation, as in the spitting of blood in pneumonia, or the sanguineous discharges in dysentery. The local hemorrhagic irritation is, however, not always accompanied with an increased momentum of the general circulation. On the con- trary, strong local determinations, and an active hemorrhagic excite- ment, often exist in an organ, whilst the activity of the heart and arteries is depressed, and the general powers of the system languid. Thus active haemoptysis' and uterine hemorrhage often occur in per- sons of weak and irritable habits, with a small, weak, and frequent pulse. Active hemorrhages occur most frequently in young, plethoric, and irritable persons, and in those who are constitutionally predisposed to strong, irregular determinations of the blood to particular organs, as the head, the lungs, or the abdominal viscera. They occur in in- flammatory fevers, either as accidental or critical evacuations; and in this case, they are always to be regarded as favourable. In many instances, the eruption of the blood is preceded by vari- ous premonitory symptoms; but in others, the hemorrhage comes on suddenly without any manifestations of its approach whatever. Among the symptoms which announce the approach of active he- morrhages, may be mentioned, a full, frequent, rebounding (dicro- tus; bis feriens) pulse ; alternate flushes of heat and chills ; redness, tension, and fullness of the skin; increased sensibility of the sensorial organs; restlessness; anxiety; watchfulness; slight aberrations of the mind; a feeling of heaviness, pressure, heat and pain in the part; and in some instances, a turgid state of the veins, redness, and swelling in external parts remote from the organ from which the blood is about to flow. Hemorrhages are called passive when there is neither sanguineous HEMORRHAGES. 539 congestion, nor a sense of heat and fullness, but a decreased instead of an increased vascular activity, both of the general system and of the part from which the hemorrhage occurs—the exhalents suffering the blood to escape passively from want of vital activity to resist its en- trance and transmission. Some have contended that all hemorrhages are necessarily active; that the blood is always thrown out by an action of the exhalents, and not merely forced through them, as through passive tubes by the vis a tergo. This may be true ; and yet when we find some chronic hemorrhages, connected with great feebleness and relaxation, speedily arrested by remedies which all physicians are accustomed to regard as the most energetic means we have for stimulating or exciting these very vessels to increased activity, we cannot be much out of the way if we call such discharges passive. In that variety of chronic hemor- rhage which occurs in relaxed and debilitated females at the critical period of life, we possess no medicine which so promptly and safely arrests the discharge, as small doses of aloes and savin in combination —the very remedies, too, which we often find most successful to excite the menstrual evacuation ; in other words, the uterine vessels. This variety of hemorrhage depends either on mere relaxation and inactivity of the vessels, without any morbid changes in the constitu- tion of the blood, in consequence of previous disease, excessive dis- charges of all kinds, and other exhausting influences, or it is connected, and probably in a great degree dependent, on a thin, watery, or dis- solved state of the blood, and therefore incapable of communicating healthy impressions and activity to the general and capillary systems of vessels. This state is always attended with a variety of symptoms besides the hemorrhage, indicative of a relaxed, exhausted, and some- times irritable condition of the system.* Of this kind of hemorrhage (passive) are those which occur in some chronic affections, attended with great relaxation, exhaustion, and morbid irritability, such as scurvy; and in the stage of collapse of malignant and other typhous forms of febrile diseases. In some instances, the hemorrhage partakes of both the active and passive characters just mentioned. The vessels of some particular part may be habitually debilitated, inactive and relaxed, and conse- quently especially predisposed to congestion. If in this state some accidental circumstance supervenes, which increases the general mo- mentum of the circulation, or particularly favours the determination of blood to the debilitated vessels, a hemorrhage may occur, attended both with general vascular activity, and local torpor and relaxation. This occurs sometimes in hemorrhois. The effects of sanguineous discharges on the system are of course various, according to the suddenness and quantity of the evacuation, their duration, and the constitutional habit of the patient. The im- mediate effects of a considerable loss of blood on the heart and arteries need not be particularly enumerated. When the hemorrhage is ex- cessive the respiration becomes quick and difficult, the skin pale and * Jahn. Klinik der Chron. Krankheiten, bd. iii, p. 272. 540 HEMORRHAGES. cool; tremors of the extremities, chills, ringing in the ears, dimness of sight, and finally syncope, ensue. When fainting occurs, the bleeding usually ceases. In violent cases, the syncope may terminate in immediate death; but such a termination is by no means common in spontaneous hemorrhages. More or less reaction usually soon returns, and the bleeding either remains permanently arrested, or reappears with diminished activity, continuing, in some instances, with occasional intermissions, until the whole system becomes greatly relaxed and exhausted. The secondary effects of profuse or long-continued discharges of blood are often very alarming, obstinate, and even fatal. These remote consequences of hemorrhage are indeed among the most im- portant circumstances connected with sanguineous discharges, whether they be considered in a pathological or practical point of view, and deserve the greatest attention. After the immediate exhaustion of a profuse or protracted hemor- rhage has in some degree gone off, the whole system is sometimes left in an extremely excitable state. The pulse becomes very frequent, throbbing, sharp, moderately full, and compressible ; the least corpo- real exertion or mental excitement produces agitation, strong beating of the carotids, palpitation of the heart, hurried respiration, and throb- bing along the course of the abdominal aorta. In some instances of this kind, the arterial reaction becomes still more vehement. A pul- sating, deep-seated pain in the head, and a high degree of morbid sensibility of the brain occur—manifested by great intolerance of light and sound; and occasionally more or less delirium, with other mani- festations of cerebral irritation. This state of tumultuous reaction and general irritability sometimes gradually subsides, and health slowly returns. In individuals, however, of weak powers of consti- tutional resistance, this secondary excitement is apt to terminate in a state of great feebleness and exhaustion. The patient becomes slug- gish both in mind and body ; he is disposed to doze, and is inattentive to surrounding objects; the face acquires a peculiarly pale and slightly tumid appearance : the pulse is frequent, irregular, and though often large, feels as if the artery were filled with wind. The muscular powers are greatly prostrated; respiration is difficult, interrupted by deep sighs, and attended with a peculiar crepitus, changing finally to a slight, rattling sound in the trachea and bronchia. In cases of this kind death sometimes supervenes, apparently from infusion into the lungs; in other cases cerebral oppression, coma and insensibility pre- cede for several hours the fatal termination.* In many instances, however, the morbid consequences of hemor- rhages are of a much more chronic character. When the blood-vessels are much drained by copious or protracted sanguineous discharges, absorption always goes on very actively.t They soon become reple- * Dr. Marshall Hall. Medical Essays, p. 41. t The experiments of Magendie and others have fully demonstrated this fact. Under the head of dropsy, I have entered more fully into the pathological circum- stances which result from this principle. HEMORRHAGES. 541 nished, therefore, with a crude and watery fluid; the blood is greatly attenuated—containing often but a few ounces of cruor in a pound of the fluid. In consequence of this state of the blood, the heart and arte- ries are irritated; all the animal and organic functions become enfee- bled and sluggish ; the face and inferior extremities become more or less oedematous; and the whole surface acquires a peculiarly pale, exsanguineous, leucophlegmatic appearance ; the mind is torpid ; the countenance anxious, or vacant and apathetic; the heart palpitates strongly on the slightest exertion ; the hands and feet are cold ; the thirst usually very considerable; and the appetite variable, and attended with gastric pain or uneasiness, flatulency, sour eructations, and other dyspeptic symptoms. If the urinary secretion is small, general anasarca, or other forms of dropsy ensue; or colliquative hemorrhage may return, and finally extinguish life. Causes.—The degree of constitutional predisposition to hemor- rhagic discharges varies much in different individuals. Some per- sons appear to be particularly indisposed to spontaneous hemor- rhage ; whilst others, on the contrary, are naturally very prone to discharges of this kind, although in other respects of vigorous and healthy constitutions. In some individuals, there exists so great a constitutional hemorrhagic predisposition, that the slightest wound of the skin is apt to cause the most alarming discharges of blood, and which no applications are, in some instances, able to arrest. It ap- pears, moreover, that this extraordinary tendency to hemorrhage is sometimes hereditary. Fordyce relates the case of a man who bled almost daily from the nose. All his children were extremely subject to epistaxis, and one of them died of this affection. Several very remarkable instances of this kind are reported in the second number of the American Medical Review. It appears, also, that the predisposition to the different varieties of hemorrhage varies with the age of the individual. During childhood, hemorrhages are most apt to occur from the nose ; between puberty and the thirtieth year of age, hemoptysis would seem to be most common; in middle life, haemorrhagefrom the rectum occurs most frequently : and in very old people, haematuria is not uncommon.* With regard to the occasional or exciting causes of hemorrhages, it may be observed, that whatever is capable of producing strong local determinations to soft and very vascular structures, particularly the mucous membranes, may give rise to effusions of blood. The following are the principal causes of this kind. High atmospheric temperature suddenly succeeding cool and damp weather; sudden * Cullen's First Lines, vol. ii. The explanation of these circumstances, as given by Cullen, though ingenious and plausible, is far from being satisfactory. It rests too much on the mere mechanical or hydraulic character of the blood- vessels. The intimate relation subsisting between the nervous and vascular systems as vital structures, and the various sympathetic relations between the different organs themselves, subject to variations according to age, are probably much more concerned in the development of these and other predispositions, varying by age, than the circumstances mentioned by Cullen. 542 HEMORRHAGES. diminution of atmospheric pressure—hence the aptitude to haemo- ptysis and epistaxis on ascending high mountains. Various causes tending to obstruct the free return of the blood to the heart; such as ligatures, tumours pressing upon large venous trunks, tight cravats, visceral indurations, and tightly laced corsets; cold repelling the blood from the surface to the internal vessels. Causes that suddenly and greatly increase the momentum of the general circulation, as violent exercise, lifting heavy weights, stimulating ingesta, and violent mental excitement. Exertions that agitate, or over-exercise particular organs, as loud singing, long-continued speaking, vehe- ment laughing, blowing wind instruments. Substances irritating particular organs, such as cantharides and turpentine acting on the kidneys, sternutatories, or acrid and stimulating inhalations irritating the respiratory organs. General plethora, and obstructions of habit- ual sanguineous evacuations, particularly amenorrhoea. Finally, gastro-intestinal irritation, giving rise to strong determinations to the chest or head. Hemorrhages of the active kind frequently occur as critical evacua- tions ; more especially in the synochal grades of fever. Passive san- guineous discharges are never critical, or, more correctly speaking, perhaps never appear in connection with a favourable change of the malady in which they occur. In some instances, hemorrhagic discharges occur periodically. Medicus has collected a number of examples of this kind in his work on periodical diseases.* Cases occur, also, in which the hemorrhage observes a strictly intermittent course—the bleeding returning daily about the same time, and continuing from a few minutes to several hours.t I have met with a case of intermitting epistaxis which con- tinued to recur daily for nearly a week. Recamier has related a case of epistaxis in which the bleeding returned every morning and even- ing for six days in succession.! Prognosis.—The prognosis in hemorrhages depends on the con- stitutional habit of the patient; the suddenness and copiousness of the discharge; the nature of the organ from which the bleeding occurs; its independence, or connection with local or general disease ; the character of the disease with which it may be associated; the period of febrile diseases at which it supervenes ; and the character of the occasional causes. Hemorrhage is not often fatal from the mere loss of blood. In the course of twenty-two years practice, I have met with but two instances of fatal termination from direct and immediate effects of spontaneous hemorrhage. Great diversity in relation to the power of sustaining sanguineous discharges occurs in different individuals. In some, immediate and alarming prostration is produced by comparatively small discharges of blood. Others will sustain exceedingly copious evacuations with but little immediate inconvenience, and speedily recover their usual vigour and health * Fr. Cas. Medicus. Geschichte Periodischer Krankheiten. Hanover, 1784. t Red, loc. cit., bd. iii, p. 38. X Rev. Medicale, Feb.. 1827. HEMORRHAGES. 543 The quantity of blood which may be lost without any dangerous or ill consequences, is indeed, in some instances, surprisingly great. Bertholini relates a case in which sixteen pounds of blood were dis- charged from the stomach without any serious consequences. In another instance, he says, the quantity of blood lost from the nose, in the course of three days, was still greater.* Nicholai also mentions extraordinary instances of this kind, (Pathologie, b. vi, p. 353.) Hemorrhages, depending on chronic visceral disease, are in general more intractable than such as are free from disorder of this kind.— When they occur during the stage of excitement of fevers, their effects are usually salutary, and should not be checked unless they become very copious and debilitating. The hemorrhages which take place in the period of collapse always portend the utmost degree of danger; they seem to depend on a general paralysis of the capil- lary system, indicative of incipient dissolution. Hemorrhages which depend merely on the local congestion or irritation in an organ, with- out any constitutional disease, are seldom copious, and usually termi- nate spontaneously as soon as the local plethora is removed. It is different with those sanguineous discharges where the local congestion and determination are sustained by some internal or constitutional irritation. In such cases the hemorrhage is particularly apt to con- tinue long, to recur frequently, and to resist the permanent success of remedial applications. The prognosis depends also in some degree on the importance of the organ from which the hemorrhage proceeds. A hemorrhage from the lungs is, ceteris paribus, more to be dreaded than one from the stomach: and this latter is more dangerous than a bleeding from the nose. With regard to the remote consequences of copious losses of blood, it may be observed, that individuals of a relaxed, nervous, phlegma- tic, and irritable habit of body, are much more apt to suffer danger- ous secondary disorders from such discharges than persons of a con- trary physical temperament. Treatment.—The general indications to be kept in view in the treatment of hemorrhages, are: 1. To lessen the momentum of the circulation, if it be above, or at its natural standard ; 2. To diminish the determination of blood to, and moderate the local vascular action in, the part from which the hemorrhage occurs; and 3. To excite a contraction of the vessels of the part. The first indication is to be fulfilled by venesection and the exhibition of sedatives—as nitre, digitalis, cold, &c. The second indication demands counter-irritating and revulsive applications—such as cold, applied, if practicable, to the part from which the blood flows; and blisters, sinapisms, warmth and rubefacient frictions, on remote situations. The last indication requires the internal use of astringents—such as sugar of lead, alum, muriated tincture of iron, &c; and where the situation of the part will admit of it, the external application of styptics. Having made these general observations on hemorrhages, I pro- * Anatom. Quintum Renov., 375. Red, loc. cit., p. 27. 544 EPISTAXIS. ceed to the consideration of the particular varieties, according to the part from which they proceed. 1. Epistaxis.—Bleeding from the nose. This is by far the most common variety of hemorrhage. As has already been observed, epistaxis occurs most frequently in early life, particularly about the age of puberty. The eruption of the blood is often preceded by symptoms indicative of a congested state of the ves- sels of the head—as a sense of weight and tension in the temples; violent beating pain in the head ; throbbing of the carotids; flushed faCe ; giddiness; ringing in the ears; and a sense of tickling, tension, or stinging pain in the nose. In weak and irritable persons, other symptoms, in addition to these, denoting a nervous and spasmodic condition of the system, are apt to occur—namely, slight creeping chills; disposition to syncope ; cold extremities; a constricted state of the skin; and a small, corded, and quick pulse. In general, only a few ounces of blood are discharged, and with this small loss of blood all the foregoing symptoms disappear. Sometimes, however, the blood flows so copiously and continuedly as to become alarming, and to demand active measures for its suppression.* The blood very rarely proceeds from both nostrils. Causes.—The exciting causes of epistaxis are exceedingly various. Whatever has a tendency to produce a preternatural determination of blood to the head, may give rise to this variety of hemorrhage; such as insolation, stimulating ingesta, protracted study, the warm bath, sneezing, coughing, playing on wind instruments, violent par- turient efforts, straining in evacuating the bowels, a depending posi- tion of the head, violent affections of the mind,< strong blushing, intestinal irritation, heavy lifting, &c. Chronic visceral disorders, particularly indurations of the spleen and liver, strongly predispose to epistaxis, and this hemorrhage appears sometimes to be the conse- quence of organic affections of the heart and of the large vascular trunks. Suppression of the menstrual and hemorrhoidal evacuations, may give rise to this hemorrhage ; and it never fails to occur in that attenuated and watery state of the blood which usually follows copi- ous sanguineous and other evacuations, in relaxed and leucophleg- matic habits. Bleeding from the nose is no uncommon occurrence in dropsical patients, and in the latter stage of cachectic diseases, particu- larly scurvy. Prognosis.—Epistaxis is seldom of much consequence when it is not symptomatic of some serious visceral or general affection. When, however, it occurs readily and frequently in early life, it would seem to indicate a particular predisposition to haemoptysis and phthisis pul- monalis; and frequent or habitual epistaxis, in middle and advanced * Plouquet has collected a number of instances in which unusually large quan- tities of blood were discharged from the nose without fatal consequences.—BibUo- theca Medico-Pract., vol. iv, p. 69. EPISTAXIS. 545 age, may be regarded as a pretty sure indication of the existence of organic visceral disease, and of a strong tendency to dropsy or apo- plexy, according to the general physical temperament and structure of the individual. Hemorrhages from the nose, in inflammatory fevers, and in the stage of excitement of every form of fever, typhus as well as malignant, are to be regarded as salutary; but when they occur in the sinking stage, or period of collapse, they manifest a highly danger- ous condition. This, as indeed all other varieties of hemorrhage, is most apt to become troublesome and dangerous in debilitated, relaxed, and irritable subjects; more especially, when the blood, at the same time, is thin and watery, or dissolved, as in scurvy. The most un- manageable hemorrhages from the nose are those which depend on some abdominal irritation or obstruction, in connection with an at- tenuated state of the blood. Epistaxis is, however, very rarely fatal from the immediate effects of mere loss of blood, although, like other varieties of sanguineous discharges, it may lead to a train of distress- ing and dangerous chronic affections. Treatment.—In being called to a case of epistaxis for remedial aid, the first and most important question is:—Are the circumstances preceding and accompanying the hemorrhage, and is the hemorrhage itself of such a character as to render it most proper to arrest it, or to suffer it to go on until it ceases spontaneously? When the hemor- rhage occurs in consequence of suppressed menstrual or hemorrhoidal discharge, it ought not to be interfered with, unless it becomes exces- sive ; and the same observation applies to the occurrence of this eva- cuation in the stage of excitement of febrile affections. In general, whenever epistaxis is attended with an active pulse, and symptoms of cephalic congestion, no attempt should be made to arrest the bleeding by local applications ; but, on the contrary, nature should be assisted in the reduction of the vascular excitement by venesection, rest with the head in an elevated position, cold, drinks, laxatives, and nitre. The last article, given in large doses, is often particularly beneficial, in cases of considerable arterial excitement. I have used it in every variety of active hemorrhage with prompt and complete success, with- out any auxiliary application. This mode of proceeding is especially necessary in persons of robust and plethoric habits, and in such as are subject to hemorrhoidal discharges. But when nasal hemorrhage occurs in weak, nervous, and cachectic individuals, and particularly when the manifestations of general vascular turgescence and increased momentum of the circulation are absent, the sooner it is arrested the better.* In moderate cases, it will often be sufficient to apply cold water to the temples, head and nape of the neck, while the head is kept in an elevated position. Richter asserts, that cold water applied to the * [In severe nasal hemorrhage I generally succeed by nauseating doses of tartar emetic, and the action of a blister on the nape. In extreme cases, it is best to plug the nostrils in the posterior orifice, by a plug of lint or sponge brought forward from the throat, by Bellocque's canula, and in part by a common plug that will fill the anterior nostril.—Mc] vol. I.—35 546 EPISTAXIS. genital organs, has a sudden and powerful effect in arresting bleeding from the nose. If the hemorrhage should not yield to these simple measures, small doses of sugar of lead may be given internally. This is decidedly the best internal astringent in every variety of active hemorrhage.* From one to two grains may be given every half hour until the bleeding ischecked; and, in most cases,its effects are promptly successful. The gallic acid, also, is said to be a very powerful styptic for the cure of this and other varieties of internal hemorrhage. Dr. A. T. Thomson has lately published the result of his analysis of Ruspini's celebrated styptic, and from this it would appear, that its active principle is the gallic acid. Ruspini's styptic is, according to Dr. Johnson's experience, "unquestionably the most powerful restrainer of hemorrhage which we possess;" and as its price is " enormous," it is much to be hoped that Dr. Thomson's analysis may be correct. Be this as it may, experience has shown that the gallic acid is a powerful a sent for restraining internal hemorrhages. In general, the hemor- rhage may soon be permanently arrested by these means; but where the hemorrhagic disposition is strong, or in relaxed and debilitated habits, the bleeding, though checked for a time by applications of this kind, is apt to return again and again, until the system becomes greatly exhausted. In cases of this kind, we may generally succeed in putting a permanent stop to the discharge, by applying a blister to the back of the neck; and in order to obtain vesication speedily, the skin, where the blister is to be applied, should be previously well rubbed with the terebinthinate decoction of cantharides, oil of monarda punctata, or some other active rubefacient. Warm pediluvium is always a useful auxiliary remedy, by deter- mining the circulation to the inferior parts of the body; or, instead of this, sinapisms may be applied to the ankles or soles of the feet. Local styptics are recommended in obstinate cases, but they are very rarely of much avail, and may even do mischief by the irritation they cause in the Schneiderian membrane, and the consequent afflux of blood. Nevertheless, in obstinate and alarming cases, a dossil of lint, dipped in some astringent solution, should be introduced into the nostril, and passed up to the part from which the blood issues. In general, however, simple compression, by plugging up the nostril with lint, will answer all the purposes that can be obtained from applica- tions of this kind. The patient must be cautioned against blowing his nose, as well as against every thing which may excite the arterial system. Upon the whole, bleeding, purgatives and nitre, with cold water to the head, warm pediluvium, or sinapisms to the feet, blisters to the back of the neck, the internal use of the sugar of lead, and finally, mechanical compression, are the remedies which must be relied on in this variety of hemorrhage. * Various other internal astringents have been recommended—as, the sulphate of zinc, alum, sulphate of copper, gum kino, and the muriated tincture of iron. They are, however, greatly inferior to the sugar of lead. H.EMATEMESIS. 547 2. Hemaiemesis.—Hemorrhage from the Stomach. The premonitory symptoms of hemorrhage from the stomach era, in general, conspicuous. They consist in a sense of weight and pres- sure in the epigastrium; loss of appetite, or voraciousness; foul breath; acid eructations; pain and tenderness in the hypochondria; nausea ; anxiety; ringing in the ears; disposition to syncope ; a small, contracted, and irritated pulse; alternate flushes of heat and chills ; palpitation; cold extremities; a pale and contracted countenance; and finally, extreme anxiety ; and weakness and constriction about the breast; the senses become confused; great sickness of the sto- mach, with a feeling of approaching syncope; and at last, copious ejections of blood from the stomach ensue. The blood thrown up is generally of a very dark colour, sometimes in coagulated clots, and at others quite fluid. Occasionally, however, it is florid and liquid. Instances are mentioned, in which small masses of concreted lymph, deprived of the cruor, resembling pseudo-membranous struc- tures, were thrown up.* Sometimes the blood ejected is of a black colour, resembling tar. In cases of this kind, the hemorrhage pro- bably proceeds from the liver. In malignant fevers, particularly in yellow fever, the discharge resembles coffee-grounds suspended in a glairy fluid. This would seem to be generally the case when the hemorrhage arises from inflammation and abrasion of the mucous membrane of the stomach. In some instances, partial syncope fol- lows the vomiting, and the patient complains of pain in the region of the spleen and in the lower part of the abdomen. The quantity of blood thrown up at once is often very great. Instances of fatal hemorrhage in the stomach have occurred, also, in which little or no blood was discharged, (Richter;) and in some cases the blood passes off by the bowels with little or no discharge by vomiting. After the blood which had gradually accumulated in the stomach is thrown off, the patient generally soon feels greatly relieved, though often much exhausted. Very frequently, however, the same train of symptoms already mentioned return, after a longer or shorter inter- val, and terminate in another spell of vomiting of blood; and the haematemesis may thus recur several times before it finally ceases. The hemorrhage no doubt generally occurs from the mucous membrane of the stomach, but it is thought also to proceed in some cases from the liver or spleen. When the blood comes from the former organ, it passes along the common bile duct into the duode- num, and thence regurgitates into the stomach. When the spleen is the source of the hemorrhage, if this be ever the case, the blood, it is supposed, gains admission into the stomach through the vasa brevia. Richter observes that the frequent tumefaction of the spleen, a short time before the occurrence of haematemesis, as well as the morbid or unnatural condition of this organ in those who die of this disease, renders this opinion very probable. It is more likely, how- ever, that the spleen is no further concerned in the production of * Red, Feiberlehre., b. iii, p. 134. 54S HJEMATEMESIS. this hemorrhage than by the congestion which it is peculiarly cal- culated to produce in the vessels of the stomach when its own struc- ture becomes engorged or indurated. The darker and more coagulated the blood is when thrown up, the slower we may presume must have been the hemorrhage, or the longer it must have lain in the stomach. A portion of the effused blood always gains admission into the bowels, and hence generally dark, grumous, alvine discharges, occur for several days after an attack of haematemesis. Causes.—Every thing which tends to impede the free circulation of the blood in the abdominal viscera, may give rise to this variety of hemorrhage. Among the circumstances which tend most par- ticularly to this effect, are indurations of the liver and spleen. It v occurs, also, in consequence of suppressed hemorrhoidal discharge, more especially when favoured by an indulgence in the pleasures of the table, or by an inactive and sedentary mode of life. In no sub- jects, however, is vomiting of blood more apt to occur than in young females, soon after the age of puberty, labouring under menstrual irregularities. It appears also occasionally to arise from pregnancy, and from the final cessation of the menses at the critical period of life. Various local causes may produce haematemesis, such as acrid or corroding substances received into the stomach; blows on the epigas- trium ; and it takes place sometimes in the last stage of malignant fevers. The blood may proceed from the nose, and gradually descend into the stomach. This occurs sometimes in patients confined to bed by other diseases. In such cases, however, the quantity of blood thrown up is always small, and the vomiting is not preceded by the spasmodic and painful affections of the stomach mentioned above. Prognosis. — When haematemesis occurs in consequence of sup- pressed hemorrhoidal or catamenial discharge, it is not in general attended with much immediate danger, unless the vomiting returns frequently, in which case it seldom fails to lead to a train of distress- ing and dangerous consequences, such as dropsy, inveterate dyspep- sia, hysteria, hypochondriasis, and great languor, relaxation and debility. It is most dangerous when it arises from visceral obstruc- tions, particularly in persons who are addicted to the intemperate use of spirituous liquors. There is no variety of hemorrhage more apt to become habitual than this one. Tissot relates a case which recurred regularly every month, instead of the menstrual evacua- tion, without any evil consequences whatever. Treatment.—The momentum of the circulation must be dimi- nished by venesection when it is above the natural standard. A large sinapism should be immediately applied to the epigastric and hypochondriac regions, in order to derive the blood as much as pos- sible from the vessels of the stomach. Dry cupping may also be beneficially used for this purpose; and warm pediluvium will assist materially in deriving the circulation from the congested abdominal viscera. Laxative enemata should be administered. In that variety of haematemesis which attacks females between puberty and the age of thirty, purgatives, according to the experience of Dr. Hamilton, HEMATURIA. 549 are among our most valuable remedial means. There is generally, in cases of this kind, considerable menstrual irregularity, caused apparently by a loaded and torpid state of the intestinal canal. Free purgation, by exciting the portal circulation, and removing the intes- tinal irritation, will generally prevent the recurrence of the hemor- rhage in cases of this kind. I have in a few cases known decided benefit obtained from the use of active and repeated purgatives in this affection. Dr. Sheridan has published some cases which go to show that emetics will sometimes do much good in this variety of hemorrhage. He states that his father had used this remedy with great advantage in haematemesis, more than fifty years ago. I have not myself em- ployed emetics in this affection; but I understand that Dr. Chapman has resorted to them with much benefit. Ipecacuanha would appear to be the proper emetic. Various astringents have been recommended in this affection. Saccharum saturni; gallieacid; muriated tincture of iron; spirits of turpentine; alum whey; muriate of soda; kino; cold water; and a variety of astringent vegetable infusions, have been employed and praised for their effects. The sugar of lead does not appear to be as efficient in this as in the other varieties of hemor- rhage, although without doubt the best astringents we possess in this affection. Indeed, internal astringents can afford but little advantage when the disease depends on obstructions of the liver or spleen, or upon some other chronic impediment to the regular circulation of blood in the portal circle. I have nevertheless derived very great advantage from the use of the spirits of turpentine with castor oil, in purgative doses, in several cases of haematemesis. In cachectic and debilitated subjects, more especially in chlorotic females, the muriated tincture of iron sometimes affords peculiar advantages. Burserius recommends the use of copious draughts of cold water in this affection. The expressed juice of the common nettle (urtica dioica), has been much extolled for its effects in this hemorrhage, and I have known it used with apparent benefit. The diet should be of the lightest and most unirritating kind, and the drink bland, cool, and acidulated. After an attack of this dis- ease, the diluted sulphuric acid will generally be useful in restoring the tone of the stomach, and checking the tendency to sanguineous effusions. 3. Hematuria.—Hemorrhage from the Urinary Organs. It is often difficult to say whether the hemorrhage in bloody urine comes from the bladder,' the ureters, or the kidneys. As it is of some importance, in a practical point of view, to form a correct opinion concerning the source of the bleeding, it will be proper to point out the diagnostic circumstances particularly. When the blood passes off unmixed with urine, or without an effort to evacuate this secretion, the hemorrhage, it may be inferred, proceeds from some part of the urethra, (stimatosis.) When the discharge of bloody urine is attended with a stinging or dull pain 550 HEMATURIA. about the neck of the bladder, and a sense of fullness and uneasiness in the perineum, accompanied with frequent painful erections, and burning pain in the glans penis and anus, and the blood comes off in small flocculi, intermixed with pretty large coagula floating in the urine, there is good reason to infer that the hemorrhage proceeds from the bladder. The coagula sometimes block up the neck of the bladder or urethra so completely as to cause complete suppression of the urine, and render the introduction of the catheter necessary to procure its evacuation. In hemorrhage from the kidneys or ureters the blood is always very intimately mixed with the urine, so as to give to the discharge a uniform bloody appearance, without flakes, or small coagulae. After the urine has stood some time, the blood subsides to the bottom of the vessel, into a uniform paste-like substance, leaving the super- natant urine clear. In hemorrhage from the kidneys, the patient in general experiences little or no unpleasant sensations in the bladder; but in the region of the kidneys more or less pain and uneasiness are always felt, and there is usually a retraction of the testicle on one side, with a feeling of numbness on the thigh. Haematuria sometimes occurs periodically. This is most apt to be the case when the hemorrhage proceeds from the neck of the bladder, and is attended with an irregular or ineffectual hemorrhoidal effort in the system. I am now attending a gentleman who has been regularly affected with bleeding from the bladder every two months for the last four years. He was formerly much troubled with hemorrhois, but since the present complaint began, he has had no hemorrhage from the rectum. This variety of hemorrhage is most apt to occur in old people— more especially in such as have been much affected with hemorrhois, or in such as are of a gouty habit. Richter says that plethoric and corpulent women are peculiarly liable to hsematuria about the period of the final cessation of the catamenia. It is not uncommon to meet with this affection in very young children during dentition. Causes.—Hematuria is often excited by calculous concretions in the kidneys and bladder, and by acrid or stimulating diuretics, as cantharides, spirit of turpentine, garlic and other similar substances. It arises also from organic affections of the urinary organs. Scirrhus, ulcerations and vascular or fleshy tumours in the bladder, ureters, and kidneys, may produce it. In some instances, the hemorrhage occurs from a varicose state of the mucous membrane of the bladder; and it would seem that a highly congested condition of this mem- brane from chronic inflammation, is sometimes the cause of this affection. When the predisposition to the disease is strong, it may be readily excited by whatever is capable of increasing the general momentum of the circulation, and particularly by mechanical agita- tion of the urinary organs. There is a gentleman in this city who has been afflicted with bloody discharges from the bladder, at sliort intervals, for more than six years. It is frequently brought on imme- diately by active exercise, and especially by riding in a carriage over a rough pavement. It is not connected with calculus, nor with pain, HEMATURIA. 551 though often accompanied with a sense of weight, pressure, and uneasiness about the neck of the bladder. One of the most frequent causes of haematuria in advanced age is an ineffectual hemorrhoidal effort, or suppression of this discharge after it has become habitual. Hemorrhage from the urethra frequently occurs in gonorrhoea, in consequence of irritating injections. This variety of hemorrhage is seldom attended with alarming effects from the mere loss of blood. When it occurs in the latter stage of violent grades of fever, it is indeed one of the most fatal signs. Frequent and copious hemorrhagic discharges from the blad- der in old people are particularly apt to lead to dropsical effusions. (Richter.) When, however, it occurs vicariously in the place of hemorrhois or menstruation, it is rarely followed by serious conse- quences ; nor is this hemorrhage attended with danger when it arises from irritating diuretics, from dentition, or from overheating, unless it be connected with considerable inflammation. Persons who have once been affected with this complaint, are in general particularly liable to a return of it from the action of any of its exciting causes. Treatment.—In plethoric and young subjects an attack of haema- turia, like any other hemorrhage in such a habit, requires a prompt reduction of the momentum of the circulation by venesection. When the hemorrhage depends on calculous irritation in the kidneys, the warm bath, assisted by opium and sugar of lead, is generally de- cidedly beneficial. A quarter of a grain of opium with a grain of sugar of lead, may be given every hour, until the pain and irritation are allayed. Free venesection should, however, be premised in such cases; and much advantage may also be obtained from cupping and sinapisms over the region of the affected kidney. Along with these measures, copious draughts of mucilaginous diluents should be taken, more especially when the real irritation arises from acrid diuretics, or other substances taken internally. The uva ursi has been much recommended for the cure of this affection; but although I have tried it repeatedly, I have never yet derived any obvious benefit from it. Dr. A. T. Thomson says that " the addition of some gallic acid to a tincture of uva ursi, will be found to answer every indication that can be expected from the employmont of astringents in haema- turia."* When the hemorrhage is not attended with symptoms of renal irritation, or pain in the region of the bladder, the muriated tincture of iron, with the free use of mucilaginous drinks, will often do much good. I have in several instances found this astringent decidedly beneficial, after the sugar of lead had failed to procure any advantages. From twelve to twenty drops of this tincture may be given three, four, or five times daily, according to the urgency of the symptoms. In all instances the diet should be light, unirritating, and digestible, and all kinds of stimulating beverages, and active diuretics, most carefully avoided.t In one case of long standing, I succeeded * Ed. Med. & Phys. Journ., Jan., 1831. t Burserius relates an instance of obstinate hematuria, which was cured by a 552 HAEMOPTYSIS. in putting a permanent termination to the hemorrhage by small doses of alum and ipecacuanha,' in conjunction with a milk diet, mucilagi- nous drinks, and the occasional use of a mild aperient. Reil recom- mends cold and bland injections into the bladder when the blood proceeds from this viscus. He mentions also strong coffee, with laudanum, taken occasionally, as useful when this affection is attend- ed with difficulty and pain in voiding the urine. In habitual haema- turia, a caustic issue on the upper and inner part of the thigh, or near the groin on the abdomen, is said to have proved very beneficial. (Richter.) In recent cases of an obstinate character, we may some- times make a successful impression on the disease by sinapisms applied over the sacrum. I have known this application to arrest a copious hemorrhage from the bladder, after various other measures had been adopted without avail. Various astringent vegetable infusions have been employed and recommended in this variety of hemorrhage, but they seem to be of little value.t In chronic and moderate cases, we may employ a decoction of logwood with occa- sional benefit. Where the blood proceeds from the urethra, cold water or ice should be kept applied to the genitals. This will seldom fail to put a stop to the bleeding. We may also inject cold solutions of the sugar of lead in cases of this kind. The patient should not be permitted to use any exercise in recent cases. Perfect rest is often essential, particularly when the hemorrhage is attended with manifest local and general irritation. 4. Hemoptysis.—Hemorrhage from the Lungs. This term is applied to hemorrhages from the respiratory passages, whether they proceed from the larynx, the trachea, or the bronchia. In its concomitant phenomena, degrees of violence, and duration, haemoptysis varies very much. In many instances the quantity of blood brought up is very small; in some cases it is discharged in con- siderable but not exhausting quantities; and occasionally the bleeding is sudden and exceedingly copious. Active hemorrhage from the lungs is often preceded by certain premonitory symptoms ; such as a feeling of heaviness and lassitude in the extremities; anxiety; stricture across the breast; short cough ; palpitation of the heart; deep and frequent sighing ; a deep-seated, pungent or burning pain under the sternum, and slight creeping chills; cold hands and feet; alternate paleness and flushing of the face; men- tal and corporeal irritability; a quick, small, frequent and corded pulse; and often a disagreeable salty or sweetish taste in the mouth. long course of milk diet without any other remedies.—Institutionum Med. Pract., vol. iv, p. 487. * R.—Pulv. aluminis gi. ----ipecac, gr. xx.—M. Divide into ten equal parts. S. Take one every morning, noon, and evening. t [A decoction of peach leaves has often proved serviceable in my hands.— Mc] HJEMOPTYSIS. 553 After these symptoms have continued for a longer or shorter period, the patient usually begins to feel a sense of warmth in the breast, t gradually rising up towards the larynx, attended with a saltish taste. Slight coughing now ensues, or an effort is made to hawk, and the blood makes its appearance. In many cases, however, the hemor- rhage comes on suddenly, without any premonitory symptoms what- ever. When this is the case, there is commonly but little blood discharged at a time : but the hemorrhage is apt to return frequently for several weeks, and even months. The blood is usually very florid and frothy, particularly when it proceeds from the trachea and larger bronchia. In malignant fevers, scurvy, gangrene of the lungs, and in the pneumonia of old people, the blood, however, is dark, and sometimes almost black, and gene- rally dissolved. When the hemorrhage proceeds from the fauces, the blood is gene- rally spit out without coughing, and when it comes from the cavity of the mouth, there is usually neither coughing nor hawking in throw- ing out the blood. In some instances, however, when the bleeding is profuse, the blood descends and irritates the glottis, giving rise to a mixed effort of coughing and vomiting, which may readily lead to the supposition that the blood proceeds from the lungs. Portal mentions a singular instance, which was treated unsuccess- fully for hemorrhage from the lungs. The quantity of blood coughed up was very copious, and although frequently checked, recurred again and again until the patient sunk under it. On dissection, the bronchial glands were found much tumefied—some of them as large as a hazel- nut, and charged with a large quantity of black fluid. The lungs were sound, but the bronchial cells were filled with a dark grumous fluid. In most instances, those who have once suffered an attack of spitting of blood, are subject to returns of it at irregular periods; and in some rare instances this affection has been known to return periodically. Schroeder mentions a case in which a considerable portion of blood was coughed up every morning for many days in succession, not the least hemorrhage having occurred during the rest of the day; and Alexander Thompson relates an instance in which hemorrhage from the lungs came on every third day with perfect regularity for upwards of a year. Reil also saw a case of quotidian haemoptysis in a female, which continued for two years. The bleed- ing always occurred in the morning. Cases in which hemorrhage from the lungs returned monthly, are mentioned by Amatus Lusitanus, Schenck, Meyer and Mead; and Richter mentions an instance in which it occurred every four weeks instead of the menstrual evacu- ation, for upwards of twenty-five years. (Spec. Therap) Blanchard saw an instance of its recurrence for a long period (every three months) in consequence of suppressed hemorrhoidal discharge.* Predisposition.—The period of life most favourable to the occur- rence of this variety of hemorrhage, is between the fifteenth and * Medicus. Geschichte Periodischer Krankheiten, th. i, p. 115. 554 HAEMOPTYSIS. thirtieth years of age. Some individuals are constitutionally predis- posed to it; and, indeed, in the majority of cases, in which it occurs spontaneously, such a predisposition lies at the bottom of the disease. This predisposition would seem to consist in an irritable state of the circulatory system generally: and in a delicate organization of the pulmonary system. The habit of body—so far as its physical con- formation may be concerned—which seems most generally connected with a particular predisposition to this hemorrhage, consists in a nar- row, flattened, and depressed chest; high, prominent, square shoul- ders; a long and slender neck ; a general slender and delicate frame of body ; fair hair, and blue eyes; a delicate and fair skin, through which the superficial veins are conspicuous; red cheeks; sound white teeth; and a clear but not powerful voice. Such individuals are of a sanguineous temperament; irritable, passionate, full of activity, but incapable of enduring much exertion; they are apt to be troubled with irregular determinations of blood, particularly to the head; and slight exciting causes create a palpitation of the heart and general arterial excitement. During early youth, persons of this temperament and habit are apt to be aflected with glandular swell- ings about the neck; eruptions on the scalp and behind the ears; and as they advance in age, with slight catarrhal affections, which frequently go off slowly with a copious expectoration. In such individuals, after they have passed the age of puberty, the ordinary exciting causes of hemorrhages are particularly apt to give rise to spitting of blood. ■Causes. —The exciting causes of haemoptysis are, of course, ex- tremely various. The following are among the most common and powerful. Atmospheric vicissitudes; violent bodily exertions ; the intemperate use of stimulating drinks; the suppression of habitual evacuations; the sudden drying up of old ulcers; repercussion of cutaneous eruptions ; suppressed habitual sweating of the feet; me- tastasis of gout; rheumatism ; irritating substances acting directly on the mucous membrane of the lungs, as the inhalation of fine irritat- ing particles floating in the air, or of gaseous substances ; intestinal irritation ; organic diseases of the heart; obstruction of the spleen or liver ; a sudden diminution of atmospheric pressure ; breathing a very heated air ; blows on the chest; costiveness; loud speaking, or singing; violent mental excitement; and organic affections of the lungs, im- peding the free circulation of the blood through its vessels, particu- larly tubercles. Haemoptysis sometimes follows the amputation of a limb or the taking up of a large artery. Prognosis.—Haemoptysis seldom proves fatal from the mere loss of blood. It is, nevertheless, generally of very serious import— being, in many instances, the forerunner or attendant of phthisis pul- monalis. It is not, however, always followed by consumption, or even connected with a phthisical habit.* Instances of pulmonary * [Louis thinks it the invariable precursor of phthisis. In this, however, he is certainly mistaken. I have had many patients live for years after repeated attacks of haemoptysis, without exhibiting any signs of tubercles.—Mc] HEMOPTYSIS. 555 hemorrhage not unfrequently occur without any dangerous conse- quences whatever; and this is more apt to be the case when the discharge comes on suddenly and profusely, than when there is an expectoration merely streaked with blood. The prognosis as to the remote consequences, depends, however, much on the presence or absence of the general manifestations of a scrofulous or phthisical habit mentioned above. Where these indications are unequivocal, the occurrence of hemorrhage from the respiratory passages is always to be regarded as highly dangerous. When this hemorrhage occurs from pregnancy or suppressed catamenial or hemorrhoidal discharge, there is usually no reason to apprehend any very serious conse- quences, if a predisposition to consumption does not exist. In gene- ral, haemoptysis, resulting from causes which suddenly produce strong pulmonary congestion, or general arterial excitement—such as lifting heavy weights, or other violent bodily exertions; loud singing or declaiming; playing on wind instruments; over-distension of the stomach ; stimulating drinks, &c.—is much less apt to lead to danger- ous consequences than cases that occur spontaneously. Treatment.—The remedial management of haemoptysis divides itself into that which is proper during the actual existence of the hemorrhage, and that which should be pursued after the bleeding is arrested. When the pulse is frequent, tense or hard, the momentum of the circulation should be immediately reduced by venesection; and to effect this purpose adequately, it is often necessary to abstract blood very copiously. In some instances, the pulse will be found very small, but tense and firm to the touch; and in such cases it is par- ticularly important to resort to prompt and very free venesection. At the same time that this step is taken, large portions of common salt* or small doses of sugar of lead, should be administered at short inter- vals, until the hemorrhage is checked. A large sinapism should also be applied over the breast, as soon as the activity of the pulse is reduced Perfect rest and cooling drinks should be rigidly enjoined. If the feet are cold, warm applications or sinapisms ought to be applied to them; and the patient may take an occasional draught of * This article was first introduced to the notice of the profession, as a prompt and efficient remedy in haemoptysis, by Dr. Rush. It would seem, however, from Schopfs account of his Travels in the United States, (bd. i, p. 116,) that the knowledge of its powers in this way was first brought to this country from Ireland, by Schiel.(a) F. Hoffman and Fordyce assert that a solution of sulphate of soda will often do more good in haemoptysis than any other remedy. (a) [Notwithstanding such high authority, I am confident that the practice is bad. Salt water increases the irritation although it tends to check the hemorrhage. It leaves the parts dry and constricted. Tartar emetic, in nauseating doses, has always acted promptly under my observation, overcoming all the irritation at the same time that it is followed by a moist expectoration which subverts the in- flammation .—Mc. ] 556 HEMOPTYSIS. cold water* If the bowels are constipated, the rectum should be emptied by laxative enemata. In cases of this kind, large doses of the nitrate of potash will often promptly arrest the hemorrhage; and in a manifestly phlogistic state of the system, it is decidedly the best internal remedy we possess in this affection. This article was long ago strongly recommended by Selle ;t and Richter speaks very favour- ably of its powers in this disease. Dickson also gave it in very large portions, dissolved in mucilaginous fluid, in this affection, with much benefit ;f and we may likewise cite the experience of Gibbon§ and Hartman|| in favour of its excellent effects. In Italy it has of late years been greatly extolled as a remedy in haemoptysis, and, according to my own experience, not more than it deserves. Recamier has within a few years reported some cases illustrative of its beneficial effects in this variety of hemorrhage. He gave half an ounce of nitre dissolved in a mucilaginous mixture, in the course of twenty-four hours, and in this way three cases were promptly relieved after bleeding and other remedies had been used ineffectually.IT From fifteen to twenty grains of this article, dissolved in a small cup of barley water, or some other mucilaginous fluid, may be taken every half or hour, until the bleeding is checked. A great variety of inter- nal astringent remedies have been recommended in this affection — such as alum, colcothar of vitriol, sulphate of copper, sulphuric acid, &c; but they are all much inferior in efficacy to the sugar of lead. This article may be given in doses of from one to five grains every half hour or hour, or at longer intervals, according to the rapidity of the he- morrhage. It appears to be equally applicable in cases attended with an active or debilitated state of the circulation. I have generally given it in union with calomel, where the diathesis was phlogistic; but in cases attended with a nervous or spasmodic condition, opium is the best adjuvant. In cases attended with an irritated, small, frequent pulse, with a pale and contracted countenance, cold extremities and a dry skin, small doses of sugar of lead, in combination with opium and calo- mel,** will generally procure prompt relief. Richter and Mezatt re- * Burserius (Inst. Med. Pract., vol. iv, p. 33), says much in favour of the use of frequent draughts of cold water, (the temperature of which is to be lessened from time to time, until it is at last taken as cold as ice.) in this variety of hemor- rhage. f Medicini Clinica. Berlin, 1797, p. 147. X Lond. Med. Obser., vol. vi, No. XVI. § Medical Cases and Remarks, Lond., 1800. || Nova Act. R. Soc. Scient., Upsal., vol. i, p. 109, as quoted in Richter's Aus- fuhrliche Arzneimittellehre, vol. iv, p. 242. IF Med. Chir. Rev., January, 1826. ** R.—Calomel gr. vi. Pulv. acetat. plumbi gr. xii. ---- opii gr. iii.—M. Divide into 12 equal parts. Give one every thirty minutes if the hemorrhage is considerable, or every two hours in less rapid cases. It Red, Fieberlehre, bd. iii, p. 107. HAEMOPTYSIS. 557 commend ipecacuanha in such cases. The former writer states that he has often promptly arrested haemoptysis, attended with cold ex- tremities, alternate flushing and paleness of the face, limpid urine, small and hard pulse, and much anxiety in the chest, by exhibiting a quarter of a grain of ipecacuanha every fifteen minutes. (Specielle Therapie.) It is in instances of this kind that emetics may be given with advantage. Whenever a congestive state of the pulmonary system is present in this affection, with deficient action of the cuta- neous capillaries, vomits will be likely to prove serviceable. They were formerly much, and too indiscriminately, recommended by some practitioners. (Brian Robinson.) In ordinary cases, attended with a plethoric and excited state of the system, they are unquestionably hazardous. In the spasmodic and nervous cases just mentioned, Harles,* Stork, Richter, Plater, and others, speak very favourably of hyoscyamus. Harles particularly recommends an oil prepared by boiling the leaves of this plant in flaxseed oil; and F. Hoffman con- siders the extract, given in doses of from one to three grains every hour, as one of our best remedies in such cases. According to Dr. Miner's experience, the powdered capsicum, given in doses of from three to five grains every ten minutes, is a most efficient remedy in haemoptysis. 1 have had occasion to prescribe this article in one instance lately, and the result has given me a very favourable im- pression of its powers in this respect. When spitting of blood assumes a chronic character, and is attended with an irritated state of the pulse, digitalis sometimes does much good. From one-fourth to half a grain of the powdered leaves, or from fifteen to twenty drops of the tincture, may be taken every four hours, until a manifest impression is made on the pulse. It will be proper to keep the system moderately under its influence for ten or twelve days. In cases of this kind, much advantage will, in general, result from blistering the breast—or, what is still better, pustulating this part with tartar emetic ointment, or establishing a more perma- nent discharge by a caustic issue or seton. The nature of the occasional cause should be particularly kept in view in regulating the treatment of hemorrhage, and especially for the prevention of its recurrence. When haemoptysis supervenes in consequence of suppressed hemor- rhoidal discharge, advantage may be obtained from the use of small doses of aloes, and particularly from the application of leeches to the anus. These measures are particularly useful in conjunction with a light' diet, moderate exercise, and an occasional general bleeding, to obviate the return of the hemorrhage from the lungs. When the disease appears to arise from general plethora, in conse- quence of a free indulgence in the pleasures of the table, and an indo- lent course of life, or sedentary habit, it will be necessary to enjoin a simple unirritating, and moderate diet, cooling drinks, moderate exercise and the avoidance of all kinds of stimulating beverages. Should the haemoptysis be dependent on irregular, gouty irritation, or rheumatism, especial advantage may be gained from setons or * Hufeland's Journal der Pract. Heilkund, b. ix, s. ii, p. 47. 558 MENORRHAGIA. issues on the inferior extremities, and a course of treatment calculated to counteract these affections. When abdominal indurations exist, or intestinal irritation from a loaded state of the bowels, or acrid secretions, a gentle course of mer- curial and aperient remedies, the extract of taraxacum, and other deobstruents, with a regulated diet and exercise, will be most likely to ensure exemption from a subsequent attack of the hemorrhage. If the bleeding appears to be excited by a violent cough, attended with irritation of the respiratory passages, expectorants, demulcents, leeching and cupping on the chest, venesection, and opiates, are par- ticularly indicated. In such cases frequent doses of flaxseed oil are said to be very beneficial.* When the cough is violent and spasmodic, and the pulse contracted and small, with a dry skin, small doses of camphor and ipecacuanha, with mucilaginous drinks, often procure great and speedy relief. (Richter, Specielle Therapie, bd. iii, p. 297.) When haemoptysis occurs in young females from menstrual irregu- larities, we may resort to the tincture of cantharides, venesection, blis- ters to the sacrum, riding on horseback, and the warm hip-bath; but the ordinary stimulating emmenagogues must be carefully avoided. When cases of this kind are attended with a chlorotic, or sluggish and relaxed state of the system, the ferruginous preparations, the tincture of cinnamon, exercise by gestation, a nourishing and digestible diet, with aloetic aperients, &c, may be properly used. I have employed the following pills with obvious benefit in two instances of this kind.t 5. Menorrhagia.—Hemorrhage from the Uterus. Uterine hemorrhage appears under a great variety of modifications, both in relation to its phenomena and causes. Under the present head, however, I shall treat only of those hemorrhagic discharges which occur in the unimpregnated state of the uterus—excluding, also, such as depend on organic or structural disease of the womb. In some instances, the menstrual secretion becomes so copious as to cause much debility and exhaustion, and to require remedial inter- ference. In many females, the flow of menses is always very large, who nevertheless enjoy a state of vigorous health. In instances of this kind, the discharge must not be regarded as morbid, or immode- rate, however copious it may be ; for if the system sustains no incon- venience from it, it is to be viewed as natural or consistent with the constitutional habit of the individual in whom it occurs. So long, therefore, as the health of the female continues unmolested by copious menstruation, it cannot be accounted immoderate, or a proper object of medical attention; but when this evacuation gives rise to debility, * Journal de Med., tom. xxx, p. 85. t R.—Prussiat. ferri gi. G. aloes soc. gr. viii. Tart, antimon. gr. ii. Conserv. rosar. q. s.—M. Divide into thirty pills. S. Take two every morning, noon, and evening. MENORRHAGIA. 559 exhaustion, and other symptoms of ill health, it amounts to a morbid discharge, and requires remedial measures. Immoderate flow of the menses must not be confounded with me- norrhagia. This latter is, strictly speaking, a hemorrhage, whilst the former consists in a mere superabundant secretion of the natural or healthy menstrual evacuation. In menorrhagia the effused blood retains its power of coagulation, or at least shows a tendency to coa- gulate ; but in immoderate menstrual discharge, it remains liquid and entirely free from coagula. Menorrhagia is sometimes preceded by various premonitory symp- toms ; such as pain and tension in the loins and pubic region ; a feeling of fullness and pressing down in the uterus; frequent desire to pass urine ; a small, contracted, and frequent—or full, wave-like, or re- bounding pulse; heaviness of the head, ringing and noise in the ears; slight and creeping chills, transient flushes, and sense of weight in the feet. In many instances, however, the hemorrhage commences with- out any indications of its approach. Sometimes a sudden gush of blood takes place, which continues to flow very copiously for a few hours and then ceases. More commonly, however, the discharge continues for four or five days, and in some instances several weeks, and goes off very gradually. When it occurs about the period of the final cessation of the menses, it is apt to become very protracted in its duration, more especially in females of plethoric and relaxed habits of body. All the consequences that have already been mentioned as apt to occur from the excessive loss of blood, are especially prone to super- vene from uterine hemorrhage. Women of a nervous temperament are liable to sudden amaurosis from excessive uterine hemorrhage, and they are especially subject to a very peculiar nervous pain in the head over the region of the orbit of one side; and sometimes they become affected with a distressing jarring noise " like that of a mill or threshing floor." (Hall.) When menorrhagia is copious, and pro- longed in its course, or recurs frequently at short intervals, it seldom fails to produce great relaxation and debility, and to lead ultimately to a train of very distressing, and even dangerous affections. Females who are much affected with this hemorrhage, become pale, sallow, weak, and dyspeptic; and in phlegmatic habits, oedema of the feet, or general anasarcous effusion, pains in the stomach, with great muscular prostration, are apt to ensue. Leucorrhoea, often extremely copious, almost universally occurs during the intervals of the hemorrhages, and contributes greatly to the general debility and relaxation. Menorrhagia may with much propriety be divided into active and passive* The former variety occurs in sanguineous, robust, florid, * Dr. Dewees thinks there is good reason to doubt the propriety of this " me- chanical distinction." He adopts the doctrine of Broussais, that all hemorrhao-es are active, and quotes Dr. Caldwell in support of this opinion. Strictly speaking there is, perhaps, no hemorrhage absolutely passive, and in which the vessels that furnish the blood do not co-operate in the production of the hemorrhage by some kind of action. In a practical point of view, however, this distinction is unques- 56Q MENORRHAGIA. , v^lthv females and is almost invariably preceded for a short ^b^he^t^i».traalMcr?ion. These cases rare^ continue more than seven or eight days, and are often attended with consider- able pain in the lower part of the abdomen, with a frequent and tense pulse, and a dry and feverish state of the skin. Passive menorrhagia is almost entirely confined to the period when the uterus is about losing its functions—and is met with only in such as have been much debilitated and relaxed by privations or previous diseases, particularly protracted and profuse leucorrhoea; or in individuals of a nervous or phlegmatic temperament, who have been subject to profuse catame- nial or menorrhagic discharges. The pulse, in cases of this kind, is small and weak; the muscular system relaxed and debilitated; the skin cool and pale; the countenance exsanguious, and expressive of anxiety and languor ; the urine generally pale; and the stomach disturbed with frequent nausea, and other unpleasant sensations. The discharge is apt to continue for three or four weeks, and some- times much longer. When in bed, the hemorrhage is usually mode- rate; but on rising, or making the least bodily exertion, the flow of blood is often suddenly increased. If the hemorrhage ceases, it is succeeded by a profuse leucorrhoeal discharge, which is quite thin or watery. Causes.—Females of vigorous and sanguineous habits are more subject to menorrhagia than the feeble. The predisposition to this hemorrhage is much favoured by whatever has a tendency to pro- duce general plethora, and by an irritable and relaxed state of the system. A luxurious and indolent life; the free use of high-seasoned and nourishing diet, wines, and cordials; tightly laced corsets; fre- quent and long indulgence in the warm bath ; habitual costiveness, and inordinate sexual indulgence, are among the most common and influential predisposing causes of active menorrhagia. Copious and protracted leucorrhoea; mental depression; deficient and unwhole- some nourishment; habitual exposure to a cold or humid atmosphere; in short every thing that is capable of relaxing and debilitating the general as well as the uterine system, may favour the occurrence of passive menorrhagia. Whatever tends to produce sanguineous congestion in the uterus tionably both proper and useful. Would Dr. Dewees not consider aloes a very improper remedy in the menorrhagia of young, sanguineous, and robust females'? He no doubt would. And why? Because experience has shown that this article is among our most efficient means for exciting the uterine vessels, and directing the afflux of blood to them. Yet this article, given in small, but frequent doses, deserves to be accounted the best remedy we possess for those protracted, ex- hausting, and obstinate uterine hemorrhages which occur in relaxed, nervous, and phlegmatic habits, about the critical period of life. When, therefore, we see a particular modification of this discharge arrested by a remedy which we are ac- customed to regard as decidedly calculated to stimulate the vessels from which it occurs—m other words, when we cure the hemorrhage by exciting applications, we nave good grounds for distinguishing it from those cases of the same affection wmcn are invariably increased by its operation. MENORRHAGIA. 561 may excite this hemorrhage; such as riding on horseback; dancing; active purgation ; the use of emmenagogues; immoderate venereal indulgence; long and rapid walking; a fall on the hips; stimiilating diet and drinks ; a loaded and constipated state of the bowels; sup- pressed hemorrhoidal discharge; induration of the liver or spleen; and reading voluptuous novels, &c. Treatment.—The indications in this, as in the other varieties of hemorrhage, are, to remove the predisposing and exciting causes if practicable ; to lessen the momentum of the general circulation, if it be not below the natural standard ; to derive the circulation from the uterine system; and finally, to constringe the bleeding vessels. If the pulse be active, or tense and quick, venesection will be pro- per; and every thing which has a tendency to excite the action of the heart and arteries must be removed. The patient should lie on a matress, avoid getting up or walking a;bout, and take only the lightest kinds of liquid farinaceous nourishment and cooling acidulated drinks. Having diminished the momentum of the circulation, recourse must next be had to such remedies as experience has shown to be capable of constringing, or in some way or other checking the hemorrhagic action of the bleeding vessels. Among these, the sugar of lead holds the first rank, and Will seldom disappoint our expectations entirely, in the active variety of the disease. From two to three grains, either alone or with a grain of ipecacuanha, may be given every half hour or hour, or at longer intervals, according to the rapidity of the hemor- rhage. When the pulse is contracted and quick, it should be given in union with moderate doses of opium or Dover's powder. I have been in the habit of giving it in such cases with about a grain of camphor and the same quantity of ipecacuanha in each dose, with the view of exciting a gentle diaphoresis. The tincture of cinnamon is, perhaps, more frequently used by the German physicians in menorrhagia than any other remedy; and my own experience enables me to speak with much confidence of its usefulness in cases unattended with considerable arterial excitement. From thirty to sixty drops of it may be given every hour or two. I have,in some instances, known the discharge very promptly moderated by this medicine alone. A great variety of other astringent remedies are recommended in the books, for the treatment of this hemorrhage. Alum, the extract of rhatany, kino, the sulphate of copper, &c, may, no doubt,be used with occasional advantage; but they are not equal to the sugar of lead for arresting sudden and rapid menorrhagic dis- charges. In cases attended with a moderate and protracted flow of blood, the extract of rhatany will often afford mucb>advantage ; and in instances of this kind, I have also used alum, in union with ipeca- cuanha, with marked benefit.* Tannin has lately been administered in uterine hemorrhage or menorrhagia, with marked success. M. Chavalier prescribed this article in doses of two grains every two * K.—Pulv. sulph. aluminis Qi. Pulv. ipecac, gr. xii.—M. Divide into six equal parts. Give one every three or four hours. vol. I.—36 562 MENORRHAGIA. hours, in a case of uterine hemorrhage, after a great variety of other remedies had been used with little or no advantage. " On the first day, some amendment was perceptible; on the second, the discharge was but very slight; and on the third day, hemorrhage was completely arrested, giving place to an abundant leucorrhcea; but this also dis- appeared under the continued use of the tannin. M. Chavalier em- ployed this remedy in several other obstinate cases of menorrhagia, and always with the happiest effect."* In cases accompanied with increased arterial excitement, the nitrate of potash, given in large doses, will often afford prompt relief. When the hemorrhage is pro- fuse and rapid, cold applications to the vulva and region of the pubis should be made. We may also resort to cold and astringent injec- tions into the vagina. When the violence of the discharge has been in some degree checked, and it continues in a moderate degree, the elixir of vitriol, diluted in cold water, may be taken at short intervals with advantage. Should the measures already indicated fail to arrest or sufficiently to moderate the hemorrhage, recourse must be had to the tampon. A strip of soft linen should be introduced by pushing it gradually into the vagina on the point of the finger, until the exit of the blood is obstructed. This will cause the formation of a coagulum, which, being immediately in contact with the bleeding surface, pre- vents the further progress of the effusion. Emetics also have been recommended for the suppression of uterine hemorrhage; and in active cases of a protracted character, attended with symptoms of gastric dis- order, an emetic dose of ipecacuanha will occasionally do much good.t Perfect rest, a light simple diet, and cooling drinks, must be enjoined, and all mental agitation carefully avoided. In passive and protracted hemorrhage from the womb, attended with the symptoms mentioned above as indicative of this variety of menorrhagia, little or no permanent advantage can be obtained from astringent and cooling remedies. These hemorrhages are, indeed, often extremely obstinate in their course. From much attention to cases of this kind, I am satisfied that the appropriate remedies are such as tend to invigorate the uterine vessels. Blisters to the sacrum will, in some instances, do much good; but the remedy which has most frequently succeeded in my hands, is a combination of aloes and the prussiate of iron,{ in conjunction with the tincture of cinnamon. With these medicines I have often succeeded promptly in arresting such hemorrhages. Dr. Dewees recommends small doses of hiera picra, a combination which I have known very effectual in several cases. Aloes is an old remedy in this variety of hemorrhage. Burdach, in his Materia Medica, mentions its usefulness in such cases. Ergot may also be used with a prospect of advantage; and I have even resorted * Revue Medicale, September, 1828. t Eberle's Mat. Med., vol. i. p. 27. Second edition. X R.—Prussiate ferri Ji. G. aloes gr. v. Conserv. rosar q. s—M Divide into twenty pills. Take one three times daily. PHLEGMASIA DOLENS. 563 to the more active emmenagogues, such as the extract of savin, with evident benefit; and in no instance with disadvantage. The savin has, indeed, been highly recommended by several German writers, in uterine hemorrhages of this kind. Dr. Feist asserts, that in menor- rhagia of long continuance, attended with a sluggish and relaxed habit of body, and a pale and fetid discharge, prompt and complete relief may, in general, be obtained from the use of savin.* He recom- mends the following formula for administering this article. R.—Pulv. folior. sabin. Jjiii. Extract, sabin. 3d. 01. sabin. Qi.—Divide into three grain pills. Take four three times daily. Dr. Gunther, of Cologne, also, has published an account of some cases of profuse and long-continued menorrhagia which yielded to the extract of savin given in scruple doses.t The prussiate of iron, in doses of from ten to fifteen grains, has been employed by some practitioners with much success; and I do not doubt, from what I have seen of its powers, that it may be very beneficially given in this form of passive hemorrhage. We may also resort to the muriated tincture of iron in cases of this kind. I have lately succeeded in put- ting a stop to a protracted hemorrhage of this kind, by a mixture of the compound tincture of aloes and the muriated tincture of iron, according to the following prescription. B.—Tinct. aloes compos. ---- ferri. muriat, aa ^ss.—M. Take twenty drops four times dady. CHAPTER XX. PHLEGMASIA OF THE LYMPHATIC SYSTEM. Phlegmasia Dolens. Tnis singular phlegmasial affection is almost exclusively confined to females in the puerperal state; and is characterized by a pale, tense, elastic, and extremely tender swelling of one of the inferior extremities; communicating to the touch a feeling of numerous in- durated nodules and ridges under the skin; and attended with more or less fever, usually of a hectic character. As has just been stated, phlegmasia dolens is almost exclusively a puerperal affection; and it appears from general observation, that the most common period of its attack varies between the fifth and ninth days after parturition. It is asserted by some writers, (Good,) that * Gemeinsame Deutsche Zeitschrift fur geburtskunde. t Rev. Med., Jan., 1827. 564 PHLEGMASIA DOLENS. this disease has "never been known to affect any other part of the body than the lower extremities;" but Cams and some other authors mention instances of its occurrence in the superior extremities. In general, the first manifestations of the disease are: pain and stiffness in the groin of one side, preceded or accompanied with chills or strong rigors, followed speedily by the ordinary train of pyrexial symptoms. Occasionally, though rarely, the disease commences by pain and swelling in the foot, an instance of which I saw about fifteen years ago. Wherever the starting point of the disease may be, the swelling more or less rapidly extends itself over the whole limb, and continues to increase until the extremity becomes enor- mously distended and exquisitely painful to the touch. To the sight the swelling exhibits an even and uniform surface; but when the hand is lightly pressed over it, a number of hard ridges and little indurations are felt apparently immediately under the skin. The skin presents a pale or white, smooth, and glabrous appearance, and is preternaturally warm to the touch. In general, the swelling ex- tends to the labium pudendi of the affected side, leaving the opposite labium and contiguous parts entirely free from tumefaction and pain. More or less tenderness is generally felt in the iliac region of the affected side, and the track of the round ligament is especially apt to become painful or tender. Mr. Trye, indeed, considers the tender- ness in the course of the round ligament as a pathognomonic symp- tom. Position produces no change in the swelling, as is the case in oedema. When the disease is at its height, the skin of the affected limb is much whiter than that of the sound side; and its temperature is always very considerably augmented. The disease is always attended, from its commencement, with considerable irritative fever, and the patient is generally extremely restless, and tormented by her sufferings. The duration of the disease is very variable. It seldom, however, terminates under two weeks; and it may be prolonged to the fifth week, and even to a longer period. When it is about declining slight sweats break out over the whole surface of the body, and the urine deposits a reddish sediment whilst the fever progressively abates. The declension of the swelling is always very gradual, and the leg very rarely returns to the size of the sound one. Some degree of stiffness of the muscles of the leg usually remains after the total sub- sidence of the disease ; and the skin continues for many months to be less movable on the subjacent parts than in the sound state. In some instances, though very rarely, the inflammation termi- nates in suppuration ; and when this happens, the cellular membrane sloughs out from between the skin and muscles, as in the suppuration of erysipelas. The occurrence of this accident is always attended with the utmost danger. The only two fatal cases I have ever seen terminated in this way—a termination which, in both instances, was caused by the ruinous treatment of an empiric, under whose mis- management the cases were placed. In general the breast becomes flaccid, and the secretion of milk is in part, or even wholly suspended. It is singular that this fact should PHLEGMASIA DOLENS. 565 be denied by Dr. Good ; for I can affirm, that I have never met with an instance of this malady, in which the lacteous secretion was not conspicuously diminished. Dr. Huston, of this city, in a well-written and interesting paper on this disease,* declares that "in all the cases he has seen, the secretion of milk was diminished, and in some wholly suspended during the violence of the disease;" and the same observa- tion is made by nearly every writer on this subject I have consulted. In relation to the etiology and nature of this affection, writers have expressed a great variety of opinions. By many the disease has been ascribed to a metastastic transference of the lacteous secre- tion from the breasts to the affected limb, giving rise to the deposi- tion of milk into the cellular tissue of the extremity. This opinion was advocated by Puzos, Levret, Astruc, Doublet, Mauriceau, and by nearly all the German writers on this subject until a very recent date. Others have ascribed the disease to an obstruction of the lym- phatics at the brim of the pelvis, by the pressure of the child's head during parturition, giving rise to over-distension and consequent rup- ture of the lymphatics, whence effusion and accumulation of lymph in the glands and cellular tissue of the limb ensue. This doctrine was advanced by Mr. White, of Manchester; but its fallacy has been abundantly exposed by various writers. Denman and others maintain that phlegmasia dolens consists essentially in lymphatic inflammation, commencing in one or more lymphatic glands in the groin, and thence extending along the lymphatic branches, until the whole limb becomes affected. The primary inflammation of the inguinal glands is excited, he thinks, by the acrid matter which is absorbed from the vagina. Dr. Hull conceived the disease to consist of inflammation of the muscles, cellular tissue, and inferior surface of the cutis, giving rise to a sudden effusion of serum and coagulable lymph into the cellular texture of the extremity; and according to Dr. Hosack, the inflammation occurs in all the structures of the limb —in the blood-vessels, absorbents, muscles, cellular membrane, skin, &c. In relation to this latter opinion, Dr. Huston very justly observes that it is difficult "to conceive of an inflammation of all the blood- vessels of a limb, without the appearance of redness; or of such extensive inflammation as that involving every tissue of a part, without its termination in suppuration, gangrene, or other bad con- sequences, far more frequently than happens in phlegmasia dolens." More recently, Dr. Da vies, of London, has published some obser- vations, tending to show that phlegmasia dolens is the result of an inflammation of one or more large veins " terminating in the formation of artificial membranes and other obstructions within their cavities, whereby the free return of the blood from the extremity is prevented." This doctrine is also sanctioned by M. Velpeau ; but the phenomena of phlebitis are certainly very different from those which characterize phlegmasia dolens ; and there does not, on com- paring these affections, appear to exist any reasonable grounds for this opinion. (Dewees, Huston.) * North American Medical and Surgical Journal, vols. iv. and v. 566 PHLEGMASIA DOLENS. Whatever we may think of the mode of origin, or the location of the morbid condition which constitutes this affection, there can be no doubt that it is essentially an inflammatory affection; and there exists the highest degree of probability, that the whole system of lymphatic vessels of the limb is engorged and greatly distended with lymph, at the same time that some effusion may occur into the subcutaneous and intermuscular texture. The following sentiments, expressed by Dr. Huston, are entirely accordant with my own views on this subject, and as they embrace a clear summary of the arguments on this point, I cannot do better than to adopt his language. "I believe it to consist in a complete 'engorgement' of the whole lymphatic system of the affected limb; produced by an inflamed condition of the different conglobate glands, through which the chief lymphatic vessels have to pass, on their way from the affected part, to the thoracic duct. " This inflammation may occur either primarily in one or more glands, or first in a principal lymphatic trunk, and thence extend to the glands. And this may originate either, 1st, from the gland or lymphatic trunk being bruised by the passage of the child's head through the pelvis during labour: or 2d, from exposure to cold, and especially a damp or humid atmosphere ; or the putting on of ill- dried clothes, during the irritable condition of the female system which attends the puerperal state: or 3d, from the absorption of some acrimonious matter, whereby the internal surface of the lym- phatics themselves may be excited to inflammation, and thence ex- tended to their appropriate glands; or the matter may be transmitted to the glands, and there excite inflammation. My reasons for the opinions which have been advanced, are briefly as follows c " 1st. The fact of every woman's exposure to one of the preceding exciting causes, and frequently to all of them. " 2d. The uniform occurrence of pain or uneasiness about the pass- age of the round ligament, in the groin, and down the inside of the thigh, preceding the existence of swelling or other affection of the limb whatsoever: showing conclusively the priority of disease in the- glands and their communicating trunks. " 3d. The white colour of the affected limb; which can only be accounted for satisfactorily, by supposing an ' engorgement' of the vessels which carry white fluids; for were it congestion of the blood- vessels, as in ordinary inflammation, there would necessarily be redness, instead of the white aspect. " 4th. The state of the woman's system generally, as the pulse, tongue, hectic form of fever, &c, all of which manifest a state or condition totally different from what is observed in cases of high and unequivocal inflammatory action; evidencing a state of irrita- tion, or inflammatory action of a low or subacute character. This state of irritation may be readily accounted for, by the great disten- sion of the lymphatic vessels of the limb, throughout their utmost rami- fications, and the consequent pressure which must thence be made upon the immensity of nervous fibrils by which they are surrounded. " Lastly. Its termination; which is far more uniform, and less fatal, PHLEGMASIA DOLENS. 567 than an equal extent of inflammation, attended with congestion of the blood-vessels seated in any part of the body; proving incontest- ably, that it must have a course peculiar to itself; which course, very commonly • commencing by a diminution of pain in the iliac and inguinal regions, and next of the swelling of the parts nearest those glands, indicates very clearly the seat of the. disease to be in the lymphatic system, and especially the conglobate glands." This doctrine does not differ materially from the views given of the pathology of this affection by Trye, Capuron, Gardien, and Denman. The following appearances were noticed on post-mortem exami- nation of a woman who died of this disease soon after parturition. No remarkable morbid appearance in the uterus, excepting a very turgid state of the spermatic veins, which were very large and tor- tuous ; "the vena cava was healthy, down as far as its juncture with the renal vein, below which it was thickened, and filled with a fibrous substance, varying in consistence, and adhering to the inner coat of the vessel. On laying bare the femoral vein, the subcutane- ous cellular tissue was found to be infiltrated with serum, the gra- nules of fat much firmer and more distinct than natural, and the intervening cellular membrane thickened and opaque. The lympha- tic glands in the groin were large, full of serum, and closely matted together by a condensed cellular membrane. It was extremely diffi- cult to detach the iliac, femoral, and saphena veins, in consequence of their strong adhesions to their sheath, and the surrounding organ- ized lymph by which they were imbedded." These, together with the popliteal vein, were similar in condition to the inferior cava, except that the substance they contained was thinner, of a brown colour, and somewhat puruleut appearance. In the remainder of the saphena, and in the veins near the foot, there was a plug of coagu- lum; they were otherwise healthy. The iliac and femoral arteries contained a small quantity of blood; the other arteries were empty.* Treatment.—From what has been said concerning the general character of this disease ,it is obvious that the treatment must be decidedly antiphlogistic. Blood-letting, both general and local, is required during the early stages of the complaint. The momentum of the circulation should be at once adequately diminished, by an efficient abstraction of blood with the lancet; after which it will be especially useful to apply leeches to the affected limb, particularly about the groin, and along the track of the principal trunks of the lymphatics. Dr. Dewees advises that the leeches should be dispersed over the limb, "that their bites may not be too near each other, as they sometimes leave troublesome sores." This precaution is very proper • as I have myself known very obstinate and extensive ulcera- tion to'proceed from a number of leech-bites near the groin, in a case of this kind. In some instances the febrile reaction, though not apparently very vehement, yields with great difficulty; and many venesections are required before the pulse can be sufficiently reduced. Dr Dewees has found it necessary to bleed six or seven times before * Lond. Med and Surg. Journ., April 20, 1833 568 PHLEGMASIA DOLENS. the disease yielded; and in a case which I treated about six years ago, five copious bleedings were required before an adequate im- pression was made on the pulse. Purgatives should be freely used during the active stage of the disease. Dr. Dewees prefers the following mixture for this purpose.* In one instance I used the magnesia in union with the tincture of colchicum, with peculiar benefit. The patient was ordered to take a drachm of magnesia, with thirty drops of the tincture, every two hours. After the third dose, free purging ensued; and the result both in diminishing the general phlogistic habit, and mitigating the local symptoms, was much more conspicuous than I had ever before witnessed from purgatives, or from any other remedy in this affection. I have not since had an opportunity of repeating this practice. In general the purgatives should be of the saline kind. Diaphoretics, more especially antimony, may be employed with considerable advantage in the early periods of the disease. Tart. emetic, given in as large doses as the stomach will bear, without causing vomiting, is highly recommended by some writers, and 1 do not doubt its utility, during the active stage of the complaint. The following mixture forms an excellent diaphoretic, where, after de- cisive blood-letting, there is much general irritation.t Some writers have recommended emetics; but unless there are especial indications present for their employment, it does not appear that they are capable of procuring any material advantages. In debilitated and irritable subjects, and after proper depletory measures, in the more robust and phlogistic, opium is often highly serviceable to allay the excessive pain and general irritation which usually attend this affection. This narcotic may be very properly given in union with nitre and ipecacuanha, or, what is still better, in the form of Dover's powders, in combination with nitre. It must be particularly observed, however, that opium is in general decid- edly objectionable, so long as the general and local inflammatory symptoms remain considerable ; but in the decline of the disease, its effects are almost always highly soothing and beneficial. Among the external local remedies employed in this affection, besides the leeching already mentioned, fomentations with flannel, wrung out of hot vinegar and water; the application of a strong solution of muriate of ammonia in equal parts of vinegar and water; and, after the pain, heat and swelling begin to abate, moderately stimulating lotions—such as camphorated mixture diluted with an equal portion of brandy or whisky, &c, may be accounted the most beneficial. Some writers strongly recommend the early application * R.—Sulph. magnes. Magnesias alb. ust., 5a ^iii.—M. Div. in. chart, iii. One of these to be taken every two hours, until they operate freely. t R.—Pulv. ipecac, compos, gr. xxiv. ♦ Calomel gr. iii. Pulv. nitrat. potass. 3i.—M. Divide into eight equal parts. S. Take one every two hours. PHLEGMASIA DOLENS. 569 of blisters to the groin and to different parts of the extremity; whilst other writers, and amongst these Dr. Dewees, condemn this practice as rarely beneficial, and often decidedly injurious. My own expe- rience does not enable me to say any thing in favour of blistering in this complaint, although I haVe never known any manifest harm to result from it. Where the pain in the extfemity is very great, much relief may sometimes be obtained by bathing the limb with lauda- num, more especially after proper evacuations have been procured. Emollient poultices have also been recommended for the purpose of allaying the pain, as well as assisting in the dispersion of the swell- ing ; but in the early periods of the disease, this application appears to me calculated to do much mischief. The two cases already men- tioned as having terminated in extensive suppuration, and ultimately in death, were treated from the commencement with poultices ; but as all depletory measures were neglected, much of the mischief, no doubt, depended on the want of proper antiphlogistic means. After the fever, heat and pain have in a great degree subsided, emollient applications in the form of a poultice may contribute in some degree to the removal of the stiffness and tension of the aflected limb ; but this purpose is much more effectually answered by frictions with dry flannel; the application of a muslin roller, previously saturated with a strong solution of salt, and dried, to the whole limb; and fumiga- tions of the extremity with the fumes of burning rosin. During the febrile stage of the disease, the diet must be of the sim- plest and weakest kind. During convalescence, the aliment should be digestible and nourishing, and when the patient is left in a very debilitated state, gentle tonics may be administered. If the weather is favourable, and the patient sufficiently recovered, exercise by gestation will be highly beneficial. END OF VOLUME I. VOL. 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Elements of Mammalogy, the Natural History of Quadrupeds, with 15 Engravings. 3. Elements of Ornithology, the Natural History of Birds, with 81 Engravings. 4. Elements of Herpetology and Ichthyology, the Natural History of Reptiles and Fishes, with 66 Engravings. 5. Elements of Conchology, the Natural History of Shells and Mollusca, with 119 Engravings. 6 Elements of Entomology, the Natural History of Insects, with 91 Engravings. 7. Elements of Botany, the Natural History of Plants, with 194 Engravings. 8. Elements of Geology, the Natural History of the Earth's Struc- ture, with 200 Engravings. "A knowledge of Natural History is not only valuable, but deeply in- teresting; and no one's education can, with such facilities as these works afford, be considered complete without it."—National Intelligencer. In addition to numerous flattering notices of the American Press, the publishers have received upwards of one hundred recommendations from the most prominent professors and distinguished teachers of our country, to the superior claims of these works, and urging their introduction as Class Books into all the Schools, Academies, &c, throughout the United States. As these little books are very cheap, we hope all parents will pro- cure a set for their children for home amusement and instruction. ^338 5*® NLM032068458