v>" FlfcV \47 NOTES"' op L LECTURES ON THE THEORY AND PRACTICE OF MEDICINE, DELIVERED IN THE JEFFERSON MEDICAL COLLEGE, AT PHILADELPHIA. THIRD EDITION, CORRECTED. PUBLISHED BY GRIGG & ELLIOT, No. 9 North Fourth Street. 1840. EASTERN DISTRICT OF PENNSYLVANIA, to wit: BE IT REMEMBERED, That on the twelfth day (L. S.) of October, in the fifty-second year of the Independence of the United States of America, A. D. 1827, John Eberle, M. D. of the said District, hath deposited in this Office the Title of a Book, the right whereof he claims as author, in the words following, to wit: " Notes of Lectures on the Theory and Practice of " Medicine: delivered in the Jefferson Medical College, " at Philadelphia. By John Eberle, M. D." In conformity to the Act of Congress of the United States, en- titled, " An Act for the encouragement of learning, by securing the copies of maps, charts, and books, to the authors and proprie- tors of such copies, during the times therein mentioned." And also to the Act, entitled," An Act supplementary to an Act, entitled, ' An Act for the encouragement of learniug, by securing the copies of maps, charts, and books, to the authors and proprietors of such copies, during the times therein mentioned,' and extending the benefits thereof to the arts of designing, engraving, and etching, historical and other prints." D. CALDWELL, Clerk of the Eastern District of Pennsylvania. Philadelphia: T. K. &. P. G. Collins, Printers, No. 1 Lodge Alley. PREFACE. This little work is published expressly for the use of the students attending the author's lectures on the Theory and Practice of Medicine. It embraces little more than the main propositions and facts, which form the ground-work of the lectures; in other words—the text upon which he enlarges and comments in extemporary discourse; and which, especially, the student ought to impress upon his memory. The practice of taking notes, though at- tended with some advantages, is neverthless, on the whole, calculated to lessen the benefits to be derived from oral instruction. The train of thought and reasoning is interrupted; and the mind irregu- larly hurried along the current of the speaker's ob- servations—seizing sometimes upon remarks that are comparatively unimportant, at the expense of others of a more useful and interesting import; and losing in a great measure the general spirit and scope of the speaker's discourse—more especially when the subject is one of general disquisition. These disadvantages, it is believed, will be dimin- ished, if not wholly obviated, by works constructed on the plan of the present one. Being secure of the text, or propositions, the student may yield his mind, without embarrassment, to the explications IV PREFACE. and discussions of the lecturer. His efforts, too, in recalling to his mind the observations he may have heard from the speaker, will be greatly favored, by looking over, in private, the sketch which is thus placed in his hands. The author acknowledges, that this manual does not come up to the idea he has formed, of the pro- per construction of a text book of this kind; but, such as it is, he flatters himself, that it will in some degree answer the intentions for which it was com- posed; and with this hope, he respectfully dedicates it to those students of medicine, who do him the honor of attending his lectures. TABLE OF CONTENTS. Anasarca,....... . .211 Angina pectoris,.......208 Arachnitis, or Hydrocephalus acutus, . . . .72 Ascites,.........212 Asthma,.........204 Bronchitis, acute,.......99 Bronchitis, chronic,.......100 Cholera,.........218 Chorea,.........192 Cold,.........II Colic, flatulent,........219 Colic, bilious,........220 Colica pictonum,........223 Critical days,........28 Croup, spasmodic,.......102 Cynanche tonsillaris,......104 Cynanche trachealis,.......101 Cystitis,.........117 Diabetes,.........224 Diagnosis, general,.......13 Diarrhoea,.........216 Dropsy,.........209 Dysentery,.........87 Enteritis, acute,.......85 Enteritis, chronic,.......92 Epilepsy,........183 Epistaxis,.........156 VI CONTENTS. Erethism of the brain, Erysipelas, . Exanthemata—Small pox, Fever in general, and causes of, Fever, its general course, Fever, Intermitting, Fever, Remitting, Fever, Yellow, . Fever, Inflammatory Fever, Typhus, . Fever, Catarrhal, Fevers, Type of, . Gastritis, acute, Gastritis, chronic, Gout, Haematemesis, Hematuria, Haemoptysis, Haemorrhois—Piles, Haemorrhagiae, Hemiplegias, Hemiplegiae, chronic, Hepatitis, acute, Hydrothorax, Icterus—Jaundice, . Indigestion, Inflammation in general Inflammation, chronic, Inflammation of brain, Mental diseases—Mania, Neuroses—Apoplexy, Nephritis, . Paralysis, Paraplegia, . Parotitis, . Paralysis partialis—Local palsy, Peripneumony, % CONTENTS. Vii Peritonitis, acute,.......106 Peritonitis, chronic,.......109 Pertussis—Whooping cough,.....200 Phrenitis,........71 Phthisis pulmonalis,.......164 Pleuritis, acute,.......94 Pleuritis, chronic,.......1°° Pneumonia biliosa,.......98 Prognosis,........."** Pulse,.........20 Rheumatism, acute,.......H8 Rheumatism, chronic,......I22 Rubeola—Measles,.......141 Scarlatina,........144 Scrofula,.........237 Softening of the brain,......77 Tetanus,.........195 Variola,.........131 Variola vaccina,........136 Varioloid,........139 Varicella—Chicken pox,......I41 Verminous affections,.....: 240 ! i I NOTES OF LECTURES. CHAPTER I. OF FEVER IN GENERAL. Idiopathic—(seldom.) Symptomatic—dependent on: local irritation ----inflammation, generally seated in the mucous tissues;—frequently in the serous. Proximate Cause: located in the capillary system of blood vessels. (See Practice of Med. Chap. 1.) The morbid actions of the heart and arteries are mere sympathetic phenomena, dependent on a pri- mary local irritation of a part or the whole of the sanguiferous capillary system. The proximate cause consists: in a deranged condition of the vital properties of the capillary system---whence result irregular actions from the impression of normal and innor- mal irritants. Remote causes of fever: divided into; predisposing and exciting; There exists, however, no essential distinction be- tween the predisposing and exciting cause. Every predisposing cause may become an exciting cause, by continued or intense action. 2 10 OF FEVER IN GENERAL. Predisposition consists for the most part in: local, and rarely in mere general debility. (See Pract. Med. p. 28.) The origin of all possible causes of fever is quad- ruple. 1. Retained recrementitious materials, in conse- quence of the accidental torpor of one or more of the emnnctories. 2. Substances generated in the system, independent of organic actions, worms, acid, &c. 3. Materials generated out of the body: miasmata, heat, cold, &c, &c. 4. Snbslances generated by diseased organic actions —contagious. (See Pract.Med. p. 31.) General nature of these causes. They are irritants: Some of them invariably produce the same dis- ease, as the contagious. Certain distinct febrific causes cannot develop their morbid effects at one and the same time in ihe same system: measles and small-pox. All morbid agents act primarily on the nervous system: Through the lungs and respiratory passages, The stomach and intestinal canal. The skin, and The blood. It is highly probable that all aeriform morbific agents act on the system through the respiratory organs. Some of them may be absorbed into the circulation, land act upon the nervous extremities of the blood; others may act directly on the nerves of the mucous membrane of the respiratory passages. The for- mer mode of acting, is, I presume, generally, if not always the case. The causes of fiver are divided into three classes. 1. Sensible properties of the atmosphere: heat,coldj moisture, electricity, &c, &c. OF FEVER IN GENERAL. 11 2. Contagious—the result of organic actions. 3. Miasmata—the result of physical changes. Heat. Specific temperature of the human body, 98°. Most agreeable temperature of surrounding air, 65°. Atmospheric heat not a deleterious agent; predis- poses to the influence of morbific causes, increases the secretion ot bile; indirect cause of disease, by favoring the generation of miasmata. • Dr. Johnson observes, that solar hpat only produces the predisposition^ while terrestrial exhalations, and vicissitudes of temperature, call into action the prin- cipal diseases of warm climates. (See Pract. Med. p. 39.) Colp. No positive existence—a mere relative degree of temperature; lessens jjie action of the heart and arteries; causes a shrinking of the surface of the body; diminishes sensibility and contractility; produces irresistible disposition to sleep; and de- presses the moral and physical energies of the system, when long and intensely applied. Sud- denly or transiently applied, it excites the ner- vous system. In alternation with heat, a fertile cause of disease; the diseases resulting from its influence, mostly pneumatic, catharrhal.or rheu- matic: cold water externally applied, or received into the stomach when the body is heated and in a free slate of perspiration, often proves sudden- ly fatal. Always more injurious in its influence when accompanied by moisture. (See Pract. Med. p. 35.) Miasmata. Heat and moisture essential to the pro- duction of miasmata.* Moisture need not be abundant; inundated grounds extricate little or * It has lately been contended, that moisture is not cssent'al to the generation of miasmata: but as I believe, without good grounds.— (Ferguson.) IS OF FEVER IN GENERAL. no miasmata; hence the rainy seasons of tropical countries are the most healthy. Miasmata are sel- dom generated at a temperature below 80°; their precise nature unknown; there is reason to believe that they consist of particles of putrid vegetable and animal matter, dissolved in aqueous vapor. Chemical analysis can detect no difference be- tween the air of marshes and atmospheric air. Gaspard's experiments on putrid matters re- ceived into the body, support the opinion that 7/iarsh miasmata consist of putrid vegetable and animal matter suspended in the air. Miasmata possess greater specific gravity than atmospheric air; they are conveyed to a|consi- derable distance by currents of wind; the dis- tance at which they are capable of infecting, by being thus carried, is from two or three miles (Bancroft says, but one fourth of a mile;) storms and violent blasts disperse and render them inno- cuous; more danger in miasmatic atmosphere at night than during day; most danger about the set- ting or rising of the sun; situations are protected from the effects of miasmata, by interposing ob- stacles, as houses, walls, wood, hills, &c; long and gradual exposure to miasmata, destroys the susceptibility of the system to their more violent influence. Persons unaccustomed to them seldom escape disease, when subjected to their action. They produce intermittents and remittents, of various grades of violence. (See Pract. Med p. 40.) Contagion. A deleterious agent, generated by the living body in a state of disease. The deseases produced by this class of causes, preserve a de- termined or specific character; contagious diseases divided into chronic and acute; the latter seldom affect the same person more than once;—the for- mer may affect repeatedly; in the acute, there can GENERAL DIAGNOSIS. 13 be no relapse. Contagious matter either a pal- pable substance, or on in-perceptible effluvium; chronic contagious affect ions a I ways produced by the former, and by actual contact; some acute contagious diseases communicated both by con- tact and and through the medium of the air; that is, boih by a palpable virus and an effluvium. Typhus fever, under certain circumstances, conta- gious; appears to be propagated by effluvia only. Contagious effluvia extend but a short distance sufficiently concentrated to produce disease. The experiments of Dr. O'Ryan make it but a few feet —four or five feet; currents of air wili convey it much further; contagions rendered harmless by diffusion in the air; hence the utility of free venti- lation; contagion attaches itself to various substan- ces; the substances most apt to receive and retain if, are, wool, hair, cotton, wood,cloths, &c: conta- gion influenced by certain occult conditions of the atmosphere; contagious diseases communicated from the inferior animals to the human species. Disinfecting means; cleanliness; free ventila- tion; muriatic and nitrous vapors, lime; fumes of sulphur, and heat. (See Pract. Med. p. 56.) CHAPTER II. GENERAL DIAGNOSIS. Diagnostic signs divided into those exhibited by the countenance; the attitude; the nervous sys- tem; the digestive organs; the circulatory sys- tem; the respiratory organs; the circular sur- face; the lymphatic system; the secretions. 14 GENERAL DIAGNOSIS. The Countenance. The features to be particu- larly examined, are: the eyes; the prolabia; the nostrils; the lips; the brows. In acute simple fever; eyes and face red; respira- tion hurried; motions of the nostrils rapid. In acute sympathetic fever, these signs are absent. (Hall.) Acute pain from inflammation in the chest: fea- tures much contracted; the alae nasi acute and elevated, the nostrils contracted and expanded by the acts of respiration, sometimes a vivid flush terminating abruptly—heat inconsiderable. Dull pain in the chest: less constriction of the fea- tures; an expression of great anxiety; nostrils widely dilated before inspiration. Effusion into the lungs: countenance livid, anx- ious, turgid, with great dyspnoea, and dilation of the nostrils on inspiration. The phthisical countenance. Acute pain in the abdominal viscera: features acute; forehead wrinkled; brows knit; nostrils drawn up and acute; under lip drawn down, ex- posing the teeth. Organic affections of the heart: countenance anx- ious; vividly flushed; prolabia livid: face tur- gid, oedematous, cold. In hydrothorax, the face has a pale-livid aspect. Soporose affections: flushed, livid, tumid, eyes closed or open and fixed, mouth frequently drawn to one side. In syncope: pale, shrunk, cold, and death-like. In chlorosis: pale, exsangueous; icterode; puffy; a peculiar darkness occupying the eyelids; and extending towards the temples and cheeks, and sometimes surrounding the mouth. Distinction between the icterode appearance, and the different shades of icterus, (Hall;) the yellow- GRNERAL DIAGNOSIS. 15 ish tinge in the latter is particularly seen in the albuginia of the eyes; in the former, the eyes re- main untinged. The tinge of icterus depends on bile; that called icterode, on a morbid action of the cutaneous capillaries. (Hall.) Chronic irritation of the bowels: puffy counte- nance; upper lip pale and swollen; occurs in verminous affections and in scrofula. Attitude. The healthy attitude: Advantages to be obtained from position, in the treatment of diseases. Preternatural determination to a part, diminished by elevating such part: the head to be raised, in apoplexy; the extremities, when affected with inflammation. Supine position, with tremulous motion, indicates much muscular debility. Fever from acute local inflammation; not attend- ed with muscular prostration. Characteristic position in hydrothorax: in slight cases, head and shoulders elevated when in bed; in severe cases, inability to lie down. The erect position more urgent, when complicated with organic affection of the heart. When sitting up, hands forcibly pressed on the chair on which the patient sits; or leaning back, with the arms and hands placed behind the back. (Hall.) Thoracic effusion, distinguished from mere organic disease of the heart and lungs, by the effects of firm pressure on the epigastric region, and bodily exertion. Effects of pressure, in effusion: gene- ral agitation, cough and a sense of suffocation; not so, or but slightly in organic affections of the heart and lungs; bodily exertion excites more dyspnoea, and distress in effusion, than in organic affections. Position assumed by the patient, in abdominal 16 GENERAL DIAGNOSIS. inflammation, with acute pain: fixed, carefully avoiding all motion and pressure; generally on the back, knees drawn up, and head and shoul- ders a little elevated. Position assumed of spasmodic pains in the ab- domen: constantly changing posture, desirous of pressure on the abdomen, recumbent on the belly, &c Position on the back, with knees constantly elevated in the latter stage of acute diseases, a sign of re- tention of urine. The Tongue. Attention to be paid to its color, its surface, its shape, and the manner in which it is protruded. A white and slightly loaded tongue, indicative of slight gastric derangement and moderate febrile excitement. A clean, deep red,smooth tongue,indicates inflam- mation or high irritation of the mucous membrane of the stomach and intestinal canal. Tongue seldom much affected in acute symptoma- tic fevers, from wounds or external inflamma- mations. Florid papillae protruding through a layer of white fur, characteristic of scarlatina. (Hall.) Diagnosis, from the appearance of the tongue, be- tween phthisis, and hectic with cough, from he- patic and gastric affections: tongue natural in the former; covered with brown fur in the latter. A pale and tumid tongue, with large papillae, indi- cative of gastric debility—met with in chlorosis. A contracted and pointed tongue, frequently an attendant on cerebral or meningeal inflamma- tion. A flabby and dilated tongue occurs in congestive states of fever. (Miner.) A yellow and bitter tongue, indicative of biliary de- rangement. GENERAL DIAGNOSIS. 17 Morbid States of the Nervous System. Disturbed Sleep. Coma always denotes oppres- sion of the brain. Wakefulness, a sign of great irritation or exhaus- tion. Sudden starting in sleep—intestinal irritation from worms, &c. Hurried wakings, with a horrific sense of suffoca- tion, a sign of organic diseases of the heart. Strabismus, double-vision, signs of cerebral affec- tion. Torpor of the sense of touch. Morbid sensations. In strumous disease of the mesentery, an unusual sensibility to cold constitutes a peculiar and very early symptom. (Hall.) Pain may arise from inflammation, from spasm, and from nervous irritation. They have each their peculiar character. Inflammatory pain: tenderness of the part, in- creased by pressure; throbbing or burning con- tinuous, and attended by febrile excitement. Spasmodic pain: paroxysmal, not throbbing, nor burning, relieved by pressure, and seldom attend- ed with fever. Neuralgic pain; transient but violent paroxysms, darting along the nerves with the rapidity of lightning; no swelling, no heat, and readily re- newed by the slightest touch. Inflammatory pain, modified by the nature of the structure in which the inflammation exists. Di- agnostic inferences. Pain referred to parts re- mote from that in which the primary affection resides. Alimentary Canal. Nature and appearances of the alvine discharges. Clay-coloied faeces indicate deficiency of bile— 18 GENERAL diagnosis. met with in jaundice. Diagnosis between in- fantile remittent and hydrocephalus—the alvine discharges in the former are dark brown, or mud-like, and very foetid—in the latter, glairy dark-green, like chopped spin age. (Cheyne.) Watery'and reddish stools, like the washings of flesh. Mucous and bloody stools. Respiratory Organs. Accelerated respiration always attended with frequency of the pulse. Irregular and unequal respiration indicates cere- bral oppression;—slow, irregular, and stertorous breathing attends a high degree of cerebral com- pression. Abdominal respiration, indicates pneumonic in- flammation. Breathing with the intercostal muscles, without the accessory action of the abdominal muscles, indi- cates abdominal inflammation. Peculiar respiration in hydrothorax: inspiration quick, and with great effort; respiration slower, without effort. (Hall.) The effects of corporeal exertion on respiration: produces great dyspnoea in hydrothorax, and still more in organic cardial affections. Wheezing respiration—in asthma, cynanche tra- chealis. Hurried, panting, and heaving respi- ration, with sighing, often attends intestinal irritation and exhaustion from haemorrhage. (Hall.) Cough. When the efforts of coughing are anxious- ly repressed, there is probably inflammation in the chest or abdomen. Spasmodic cough—in pertussis—sometimes from irritation of the stomach. Sputa. White cream-like, in chronic bronchitis. GENERAL DIAGNOSIS. 19 Effects of full inspiration and expiration, as a diag- nostic* Cuticular Surface. Its temperature; its color; its state of dryness or moisture; its fulness or construction; its roughness or smoothness. A yellowish tinge indicates biliary derangement; not to be confounded with the sallowness which occurs in cancer and chlorosis. A purple or bluish color Occurs in infants, from previous foramen ovale. Dark colored or purple spots—extravasations of blood. A pale, semi-transparent skin, particularly of the prolabia and face, manifests paucity, or very serous, blood—after profuse bleedings and from anaemia. Cold skin, with a feeling of internal heat, denotes internal congestions. Color mordax—in typhus. Permanently dry and husky skin, indicates torpor or chronic disease of the liver. Urine. Small in quantity, and red in inflamma- tory affections; copious and limpid in nervous diseases. Bilious urine. The various sediments—lithates; phosphates; the former are red or purple—the latter, white or pale yellow. * See Dr. Hall's work on Diagnosis. 20 THE PULSE. CHAPTER III. THE PULSE. The pulse varies with the age of individuals; at birth it beats from 130 to 140 in a minute: mean rate for the first month, is 120; limits during the first year, are 106 to 120; for the second year, from 90 to 100, for the third, from SO to 90—nearly the same for the fourth, fifth, and sixth years; in the seventh year, pulse about 78; from the twelfth year, it differs but little from that of adult age, which is estimated at from 60 to 80, according to individual constitutions, &c. (Heberden.) The common standard of frequency may be placed at from 70 to 75 beats in a minute. (Falconer.) From the 45th to the 60th year, the pulse gradually becomes slower; after this period, it again rises in frequency. (Floyer.) Generally more frequent in women than in men. (Falconer.) Climate influ- ences pulse; more frequent in hot than in cold countries. The time of day: slower in the morn- ing than at other times; most frequent soon after dinner; slower during sleep than in the waking state. Bodily exercise accelerates the pulse; varies according to the position of the body; slowest while lying down; slower when sitting than when standing. (Dr. Robinson.) Mental excitement in- fluences the pulse; joy, and anger, render it fuller and more frequent; grief, sorrow, and fear, de- press it. Mode of examining the pulse. (Celsus, Rush.) Not to be examined immediately on entering the patient's room;—the examination to be repeated at short intervals; should be felt in both wrists, the arm having its muscles relaxed by proper positions; two or three fingers to be applied to THE PULSE. 21 the artery; thirty or forty pulsations are to be felt at each examination; examined in different positions of the dody: talking must be forbidden. Pathological Condition of the Pulse; consi- dered in relation: 1. To the force of the pulsations. 2. To the rhythm or mode of the pulsations. The most prominent and useful pathological states of the pulse, consist in: frequency, quick- ness, strength, fulness, hardness and irregula- rity. A frequent Pulse is one in which the pul- sations succeed each other with preternatural rapidity; a pulse beating more than 160 in a minute, is scarcely to be counted; great frequency of pulse always connected with great prostration of the vital energies; frequency, with fulness and strength of pulse, more dangerous than the same degree of frequency, with softness and moderate fulness. When it rises above 120, in inflammatory fevers, much danger is to be ap- prehended. (Heberden.) Slow Pulse: occurs from cerebral compres- sion—internal venous congestions, and impair- ment of the vital energies; as in apoplexy, con- gestive fevers, and malignant fevers. Quickness of Pulse: often confounded, im- properly, with frequency. Quickness refers to the suddenness with which each individual pul- sation is mader-;frequency has reference to the number of pulsations in a given time. Quick- ness, however, is generally attended by fre- quency. A strong Pulse is one which gives the sen- sation of preternatural resistance to the finger, during the diastole; not to be confounded with a hard pulse. It is hard, when the artery is felt 3 22 the pulse. firm under the finger like a tense cord, both in its systole and diastole—sometimes called corded. Strength and great frequency never united, a strong pulse seldom exceeding 115 beats in a minute; a strong pulse indicates energy of the vital powers, and is therefore favorable. A feeble Pulse, the reverse of a strong pulse: it is feeble, when the artery produces a weak impulse against the finger, during its di- astole. Feebleness and softness of pulse, not sy- nonymous—the artery may resist pressure, and yet pulsate very feebly. The pulse is soft, when the artery appears to be filled, and yet offers no resistance, vanishing by slight pressure. A very soft Pulse seldom attended with great frequency, or with irregularity; occurring in the advanced stages of fevers, favorable, when joined with great difficulty of respiration, and suffused countenance, in pneumonic inflam- mation, indicative of much danger. Full Pulse. Never very frequent; some- times much slower than natural. Small Pulse—the diameter of the artery is smaller than natural; in inflammations seated above the diaphragm, the pulse is generally full —when seated below it is small. (Borden.) Depressed Pulse: small, and apparently fee- ble, and occasionally quick, does not depend on actual debility or exhaustion, but on internal ve- nous congestion.—Blood-letting will raise this pulse; distinguished from a small and weak pulse—by attending to the prevailing diathesis__ by suffering a few ounces of blood to flow, and watching its effects—and by observing the pe- riod of the disease in which it occurs; if it is small and obscure in the beginning of acute dis- eases, we may presume it is depressed THE PULSE. 23 Intermittent Pulse: when not attended by other alarming symptoms, not in general a dan- gerous sign; pulse sometimes habitually intermits; it is said to be of dyspeptic origin; occurs fre- quently in old age, and then probably depends commonly on some affection of the heart; occurs also in affections of the brain; a very unfavorable sign, in the advanced stage of fevers, with great prostration; is said frequently to precede a criti- cal diarrhoea. (Senac, Solano, Coxe.) Unequal Pulse: synonymous with irregular pulse.—Characterised by a constant variation of the pulsations, in frequency, quickness, size, hardness, &c. More dangerous than an inter- mittent pulse. Dicrolus pulse, twice-beating. Gaseous Pulse: tumid—inflated—soap-bub- ble: always indicates much prostration. Undulating Pulse: a wave-like rising and falling of the pulse; generally large, soft, and fee- ble. When very small, it is termed creeping; highly dangerous. A morbidly natural Pulse: occurs in ma- lignant fevers; exceedingly unfavorable; can only be distinguished from a healthy pulse by the concomitant symptoms. Shattered Pulse: pulse feels like a shattered quill under the finger—occurs in opium eaters. Obstructed Pulse: artery remains equally full during its diastole and systole. The Compound Pulses. The principal are the synocha; synochus; synochula; typhoid; and typhus. 1. Synocha: hard, full, frequent, and strong; indicates high inflammatory excitement. 2. Synochus: full, round, active,but not hard: 24 GENERAL PROGNOSIS. occurs in the hot stage of intermittents; in remittents, &c. 3. Synochula: quick, tense, small, hard, vi- brating; occurs in sub-acute rheumatism— inflammation of the intestines, peritoneum, &c. It is the hectic pulse. 4. Typhoid: quick, small, slightly tense, not hard, and somewhat frequent: in the ad- vanced stages of bilious fevers—the result of irritation in an exhausted state of the system. 5. Typhus: small, very frequent, somewhat quick: occurs in the advanced stages of jail, hospital, and other varieties of typhoid fevers. CHAPTER IV. GENERAL PROGNOSIS. The evidence of a single symptom not sufficient to give a decisive prognosis; the cause, the conco- mitant phenomena, the temperament and habits of the patient, &c, must be carefully estimated. The Countenance. The more it varies from its natural expression, the more unfavorable. Hip- pocratic countenance—nose pointed, eyes sunk, temples hollow, ears cold and shrivelled, the lobes everted; skin on the forehead hard, tense, and dry, countenance pale, livid, or leaden: a fatal symptom in the last stage of acute diseases. One eye becoming smaller than the other, a bad sign; still worse (Stoll) when objects appear less to one eye: lividity of eyelids, lips, and alas nasi, GENERAL PROGNOSIS. 25 unless in chills, very unfavorable;—pointed nose, and much motion of the nostrils during in- spiration, bad. Attitude. Constant position on the back, and sliding towards the foot of the bed, unfavor- able; it betokens great prostration: same position, with open mouth, dilated pupils, or involuntary discharges, still worse. Insensibility, with mouth firmly closed and eyes fixed, a forerunner of con- vulsions; great desire to sit up, with dyspnoea, and livid countenance, fatal in pneumonic dis- eases; still more certainly fatal, when attended with a good pulse. (Baglivi.) Most favorable posture, that which approaches nearest to health; reaching into the air, and picking the bed-clothes, bad; always unfavorable, when visceral inflam- mations supervene to simple fevers; tumefaction of the abdomen, and tenderness to pressure indi- cate danger; laborious breathing, with short, irre- gular, and interrupted acts of inspiration, is a bad sign; a still more dangerous sign, is exclusive abdominal respiration, attended-with strong mo- tion of the alas nasi by the respiratory act; ster- torous breathing, attended with a rattling in the upper part of the chest, is highly dangerous, though not invariably a fatal sign; short and very accelerated breathing, always a bad sign; free and easy respiration, favorable; hiccough, in the advanced stages of fevers, indicates danger. Constant wakefulness, or somnolency, is unfavor- able—when great pain in the head, pulsation of the carotids, and a puffed red countenance attend the latter, there is much danger. Unequal dis- tribution of temperature—a sensation of cold externally, and of heat internally, are bad signs; still more unfavorable, when a sense of burning heat on the surface is attended by a feeling of cold internally. 3* 26 GENERAL PROGNOSIS. Intellectual and moral habits. When these are changed; when old associations are interrupted; new antipathies formed; when the moral become profane and loose in their language, it is a dan- gerous sign. Partial insensibility of the sensorial functions, more favorable than great acuteness in this re- spect. Intolerance of light, with involuntary flow of tears, filmy, protruded, or very sunken eyes, very bad. The excretions. Urine: black, chocolate-colored, fetid—or watery and fetid, highly unfavorable; a good sign, when after having been crude and watery, it deposites a reddish sediment—still more favorable, when attended with a moist skin, of natural warmth. Suppression of urine, in protracted and violent cases of fever, a very bad sign. Perspiration: when general, with no very low or high temperature of the skin, favorable; profuse and cold sweats, about the head, face, and on the arms and legs, highly dangerous; partial sweats, appearing in large drops, a bad sign; profuse, clammy and cold, always dangerous; and when attended with a very small and fre- quent pulse, fatal. Alvine discharges: very liquid, frothy, green—bad signs; watery reddish discharges, resembling the washing of flesh, and attended with tympanitic swelling of the abdomen, a most unfavorable sign. The expulsion of wind with crepitus, a good sign. (Rush.) Bloody stools without te- nesmus, in the latter periods of bilious, malig- nant, or other violent typhoid fevers, highly unfavorable; less dangerous in strictly inflam- matory fevers. Involuntary discharges of faeces, among the most unfavorable signs. Vomiting. Black flocculent discharges, from the GENERAL PROGNOSIS. 27 stomach, exceedingly dangerous;—less danger- ous, when the black or porraceous matter is not flocculent but uniformly mixed with the other fluids thrown up. A rumbling noise in the sto- mach, when liquids are swallowed, a bad sign— never occurs in the early periods of fever, and generally attended with meteorism. Sudden and very forcible ejection from the stomach is unfavorable—it occurs in yellow fever. (Rush.) Very frequent vomiting, with great tenderness in the epigastrium, in fevers, a very unfavorable sign. The tongue: covered with a brown or black crust, with deep cracks in it, dangerous; black and dry, with black sordes adhering to the teeth, highly unfavorable; a dark brown, contracted, hard, and shrivelled tongue, almost always fatal; tongue soft, moist, and light red, favorable; secretion of saliva, a good sign; difficulty of putting out the tongue, and then keeping it be- tween the teeth a long time, without retracting it, is a bad sign—a total inability to protrude it, alike unfavorable; a red, smooth, and shining, or a pointed, dry and red (round the edges) tongue, indicates considerable danger—it is a sign of strong gastro-enteritic inflammation. To- tal absence of thirst, with a dry and rough tongue, is a bad symptom. Besides the appearances enumerated above, a variety of other circumstances demand attention, in forming an opinion as to the probable event of diseases. Thus, inflammatory fevers are generally less dan- ferous than remitting fevers; and these latter, less angerous than typhus and malignant fevers. In general, the more a fever is connected with local inflammations—or rather, the more serious the local inflammations are, from the importance of the parts they attack, the more danger is to be apprehended. The type, too, must be taken into view. As a general rule, intermittents are less dangerous than remittents, and remittents less than continued fevers. 28 GENERAL PROGNOSIS. The more irregular the type of typical fevers, the more unfavorable. The appearance and progress of what are termed the crises will also aid in forming a prognosis. Unusual or contradictory phenomena are unfavorable; when a patient declares himself well, at the same time that the symptoms indicate considerable disease, it is a bad sign. CRISIS—CRITICAL DAYS. The ancients observed certain regular periods in the course of many febrile diseases, at which prominent changes are wont to occur, accom- panied by certain evacuations, and followed generally by temporary or permanent abatement of the symptoms. These evacuations, and their associated phenomena, are termed: Crises: No febrile or noxious matter, as was once supposed, thrown off by these critical .evacuations. Critical discharges, the effect, not the cause of the melioration of disease which follows, or attends their occurrence. The doctrine of critical days generally discre- dited at present; there is probably good foun- dation for the doctrine. Crises divided into simple and compound; in the simple, the evacuation is made through one emunctory only—in the compound, through several. The most prominent precursory phenomena (per- turbationes criticas) of crises are; an increase of all the symptoms—watchfulness, chills and rigors—tremor of the whole body—anxiety and jactitation—quick and irregular respira- tion—obtuseness of hearing—vertigo—coma, &c. There are certain days in the course of fevers, upon which crises are particularly apt to occur. These are the critical days; crises occur, however, occasionally on other days. The critical days, according to Hippocrates, are the 3d, 5th, 7th, 9th, I lth, 14th, 17th, 21st, 27th, and 34th. According to Cullen, the 20th, GENERAL PROGNOSIS. 29 not the 21st day, is the critical day—he ac- knowledges no critical day beyond the 20th. Critical days divided into perfect, secondary, and intercurrent. Galen regarded the 7th, 14th, 21st, 28th, or the septenary periods as the true critical days;—the secondary, axe the intermediate days between these septenary periods, i. e. the 4th, 11th, 18th, 25th, &c. The intercurrent days are the 5th, 9th, 13th. (Galen.) All forms of fever appear to have a tendency to some one of the principal types. A single tertian may be regarded as fever in its elementary form. In this form a paroxysm and crisis occur on every odd day. Now if we consider a continued fever as made up of tertian paroxysms, protracted and run- ning into each other, we perceive from its tendency to the original type, how the phenomena of crisis should occur on the odd days. Salutary may be distinguished from insalutary discharges by the following circumstances. To be salutary, they must be neither too copious, nor too scanty; they must correspond with the nature of the fever—haemorrhage is most salu- tary in inflammatory, and diarrhoea, in bilious fevers—perspiration is more beneficial in catar- rhal fevers than diarrhoea. A discharge from one emunctory only, seldom beneficial; perspiration is never salutary unless the urine at the same time becomes charged with a sedimentous mat- ter; and vice versa. The evacuations (critical) which usually attend the commencement of convalescence, are: Critical haemorrhages: generally preceded by in- crease of arterial action; and salutary, partly from the loss of the blood, and chiefly by the new arterial excitement by which they are at- tended. It is owing to the previous excitement of the arterial system, essential to this kind of critical evacuation, 30 GENERAL PROGNOSIS. that it cannot be substituted by an artificial abstrac- tion of blood. This fact proves, that such evacu- ations do not, strictly speaking, produce the amend- ment which follows, but that they are effects or manifestations, of a previous salutary change in the vital actions. Crisis by haemorrhage is chiefly confined to inflam- matory fevers; occurs sometimes in typhus fe- vers; epistaxis, the most common critical haemor- rhage—usually preceded by flushed face, red and suffused eyes—sneezing, ringing in the ears, &c. Critical sweat. The most common crisis; must be general over the body, attended with a warm skin and turbid urine. Its approach indicated by: a soft, full, wave-like pulse; a stinging, or itching sensation on the surface, red, warm skin, and scanty urine. Critical discharge of urine: must be copious: the morning urine best for inspection; critical urine exhibits at first, a cloud, floating in the upper part of the vessel—then a globular body about the middle—and finally a sediment; (Vogel, Richter, &c.) should be attended with a soft or moist skin; preceded by pains in the loins; fre- quent inclination to urinate; uneasy or burning sensation in the genital organs, dry, harsh skin; thirst, and a soft and active pulse. Critical alvine discharges: most frequent in bilious fevers—occur during the remission of fevers— are copious; signs of approach, a peculiar trem- bling of the under lip—stammering—a full, active pulse, pain and noise in the bowels; dis- charge of wind—moist tongue—paucity of urine. (Richter.) Critical emesis, very uncommon. By crisis, in the most general acceptation of the term, is understood that period in the course of a fever, at which a determination either to death or convalescence takes place, and in which therefore the fate of the patient is determined. This decision must necessarily always occur in the ultimate point of violence of the disease. GENERAL COURSE, &C. OF FEVER. 31 CHAPTER V. OF THE GENERAL COURSE, TYPE, AND STAGES OF FEVER. Fevers divided in relation to their course into: Acute, and Chronic. The former generally make their attack sud- denly, and proceed through their course in a com- paratively short period. The latter commence less violently, and pass slowly through their course. In general, the more violent the disease, the more rapid its progress. The course of a fever may be divided into five periods. (See Pract. Med. p. 61.) 1. The forming stage—the period between the impression of the febrific cause and the developement of the fever;—distinguished by certain phenomena, called premonitory symptoms. Its duration very various; not always attended by signs of deviation from health. In general, the more protracted the premonitory signs, the more protracted, or slow, will be the course of the subsequent fever, &c. It is. during the struggle between the system and the morbific cause—while the former is gradually yield j ing to, and passing under the dominion of the latter, that the premonitory symptoms occur. The most common premonitory symptoms are: loss of appetite: irregular bowels; yawn- ing, stretching; mal aise; interruption of or- dinary habits and appetites, such as disgust for tobacco, coffee, &c, thirst, nausea, eruc- tations, dry skin, slight chills, healing up of 32 GENERAL COURSE, &C OF FEVER. old ulcers, &c. These symptoms show that the nervous system, the digestive organs, and the skin, are the first to suffer in the evolution of fever. Some diseases have peculiar premonitory symp- toms, as the measles. A morbific cause may produce the premonitory symptoms, without being adequate to the full develope- ment of the disease. 2. The cold, or second stage: a sensation of cold almost invariably produces a febrile re- action; frequently no real subduction of tem- perature in the febrile chill; it depends there- fore often on an altered state of sensibility to heat. Symptoms attending this stage:—skin pale, contracted, dry—shrinking of the sur- face—respiration irregular, oppressed, anx- ious—a small dry cough—tongue dry—head confused, pulse small and frequent—nausea and vomiting; the sensation of cold may be generally or partially diffused over the body. The relation between the violence and dura- tion of the stage, to the ensuing stage of re- action, is direct; the former being violent and short, the reaction will most probably be vigorous; weak and protracted chills usually followed by feeble reaction. A chill occurring in an advanced period of a remittent, indicates that it is about al- tering its type or form; occurring in the ad- vanced period of visceral inflammations, in- dicates the occurrence of suppuration; crises and metastases sometimes preceded by chills. Hot, or third stage of fever: characterised by increased heat of the skin; return of the nat- ural fulness and color of the surface; pulse full, vibrating, and vigorous; pain and throb- bing in the head; eyes prominent, and very GENERAL COURSE, &C. OF FEVER. 33 sensible to light; a dry skin; urine small, and high colored. The fourth period or sweating stage: profuse and general perspiration;sedimentousurine; diminution of pains in the head, loins, &c; pulse soft and full, &c. The fifth period, or the period of convales- cence: The course of every fever is either: 1. Continued: very slight evening exacerba- tions, and morning remissions. Total absence of remissions and exacerbations very rare, if ever. Remitting: prominent and regular remissions and exacerbations. 3 Intermitting: regular paroxysms and per- fect intermissions. One paroxysm, with its intermission, consti- tutes its revolution. According to the duration of the revolution, fevers are divided into: 1. Quotidian, occupying 24 hours. 2. Tertian, do. 48 do. 3. Quartan, do. 72 do. The form which fevers assume in this respect, is called their'type. There are, therefore, three prin- cipal types: i. e., the quotidian, the tertian, and the quartan types. Quotidians generally come on in the morning; tertians about noon; and quartans in the afternoon. Tertians divided into simple and double. Double tertians: paroxysms occur daily; but the paroxysms of the alternate days are similar in violence, time of occurrence, and duration, and differ in these respects from those which occur on the intervening days. Intermittents rarely are of the double tertian 4 34 GENERAL COURSE, &C. OF FEVER. type, from their commencement; they gene- rally commence as simple tertians, and dupli- cate their type afterwards; the new or accessory paroxysms generally milder than the original; double tertians generally return to the simple type, before they terminate; a change from the simple to the double type, is unfavorable. Other variety of compound types: tertiana du- plicate/; haemitritaeus;—lertiana triplex. The quartan type is also susceptible of duplica- tion. The double quartan has two paroxysms every fourth day. Authors mention triple quartans, three paroxysms occurring on every fourth day—these are very uncommon. The difficulty of arresting the course of an intermittent, in general, is proportionate to the time occupied by each paroxysm. Intermittents are said to be anticipating, when the paroxysm comes on earlier every succeeding recurrence— and postponing, when it occurs later at each return. When the paroxysm is postponed to about eight o'clock in the evening it frequently does not come on until the next morning. In like manner, the paroxysm of an anticipating ague, occurring at eight o'clock in the morning, will have its next paroxysm on the evening of the day preceding that on which it should happen. (Wilson.) Favorable, when the paroxysms are postponed; unfavorable when anticipated. Atlypic,or erraticfevers: no regular type; rheu- matism—catarrhal fever. Fevers often change their type—the conversion of type seldom suddenly effected. INTERMITTING FEVERS. 35 CHAPTER VI. PARTICULAR FEVERS. OF INTERMITTING FEVERS. General character. A succession of regularly re- curring febrile paroxysms—commencing with chills, and terminating in profuse perspiration, with intervals of perfect remission from fever. Types: the quotidian, the tertian, the quartan, and complications of these primary types. Stages: the cold, the hot, and the sweating stages. Symptoms—Of the cold stage: lassitude, yawn- ing; skin pale and shrunk; pulse small aad fre- quent; rigors more or less strong; mind confused and inattentive—when violent, comatose; urine pale and crude; thirst great; respiration quick and anxious; lasts from fifteen minutes to several hours. Hot stage: at first, nausea and bilious vomiting; skin hot and dry: face flushed and full: pulse, full, frequent, and strong: respiration free and regular; head-ache—urine, high colored and scanty. Sweating stage: profuse perspiration; pulse soft and moderately full; urine copious and sedimen- tous; a gradual abatement of all the symptoms of the previous stage, until it terminates in the state of intermission, or apyrexia. Anomalous symptoms: the cold stage has been absent; sweat sometimes absent in the third stage, being substituted by other evacuations. Masked Agues, (Febres Intermit lent es Larva fae.) Intermittents under various assumed forms: as epilepsy, mania, hemicrania, tooth-ache, cramp 36 INTERMITTING FEVERS. in the stomach, dysentery, cholera, &c. Diag- nosis of masked agues; their periodicity; the cotemporaneous prevalence of intermitting fe- vers; slight sensations of cold, preceding the attacks; gentle perspiration, with turbid urine attending their disappearance. (See Pract. Med. p. 74.) In infants, the paroxysm sometimes commences with convulsions. Distinct rigors axe not com- mon in infants. Intermittents divided into the: In flam m a tory, Congestive, Gastric, and Malignant.—(See Pract. Med. p. 73.) 1. Inflammatory intermittents: of frequent occurrence: quotidians more apt to assume this character than tertians, and tertians than quartans. Occur most commonly in young and plethoric subjects, and in the springand winter seasons; rigors strong in the first, and action intense in the second stage; intermis- sion imperfect, the pulse retaining a preter- natural quickness and tension, and the thirst and heat of the surface remaining greater than natural; often slight pectoral affections. The primas viae seldom much loaded with bile and saburral matter; little or no mani- festation of intestinal irritation. 2. The congestive variety: not common; oc- curs in persons of debilitated habits of body— in the irritable and nervous. Cold stage, very protracted, attended with deep-seated pain in the head, vertigo, syncope, a sense of weight in the breast, coma, and a small, trembling, weak pulse. Hot stage, imper- fectly developed—the system remaining op- pressed; the surface cool; the breathing con- fined and anxious; countenance pale; pulse INTERMITTING FEVERS. 37 frequent, small, and somewhat tense, and a sense of heat internally. (Pract. Med. p. 75) 3. The Gastric variety: the majority of our autumnal intermittents are of this character: they are attended with strong marks of irri- tating matters in the primas viae; there is rfausea, bilious vomiting, bitter taste; weight and miners in the epigastrium; great pain in the forehead; foul tongue; quivering of the under lip; countenance, and tunica albu- ginia, tinged with yellow; urgent desire for acid drinks. 4. Malignant Intermittents. Rapid in their course—sweat, in the third stage, generally very copious and fetid; haemorrhages from the nose, bowels, gums, &c.; petechia; and other symptoms denoting malignity. (Ali- bert.) Intermittents occasionally cure other affections; such as cutaneous eruptions, hysteria, gout, asthma, hypochondriasis, and epilepsy. (For- dyce, Vogel.) In relation to the natural duration of intermittents, it would appear that quotidians, when left to themselves, have a tendency to terminate on the 14th; tertians on the 21st; and quartans about the end of the 6ih week. Prognosis. When simple intermittents prove fa- tal, it is generally in the cold stage—death then occurs in the way of apoplexy; most dangerous in weak and cachectic habits of body. Postpon- ing more favorable than anticipating agues; scabby eruptions, re-appearance of suppressed discharges, &c. favorable; integrity of the diges- tive functions, a good sign; change from the quo- tidian to the tertian favorable. Delirium more unfavorable than mere coma; occurs in the worst 4* 38 INTERMITTING FEVERS. forms of the disease. Tumid and painful abdo- men, with oppressed respiration, hiccough, &c; colliquative diarrhoea; bloody urine, red and suf- fused eyes—are bad signs. Great debility dur- ing the intermission, with oedema of the legs and feet, restlessness, languor, sighing, dry tongue, or bilious vomiting, very unfavorable. (Pract. Med. p. 77. Circumstances peculiar to the various types: Cold stage longer in tertians than in quotidians—hot stage longer in the latter than the former; &c. &c. CAUSES OF INTERMITTENTS. The principal—almost exclusive—cause of inter- mittents, is marsh miasmata, called by the Italians, malaria. Intermittents are the first grade of miasmatic fe- vers—most common during the autumnal months, in the marshy districts of temperate climates. The operation of miasmata is favored, by sudden changes of weather, dampness, and whatever de- bilitates the body. Miasmata often remain dormant in the system for a long time. Other causes:—worms and other irritating sub- stances in the intestines; suppressed habitual dis- charges, &c. (Pract. Med. p. 79.) Proximate Cause. Spasm of the extreme vessels (Cullen's doctrine) objected to. Irritation and inflammation of the mucous mem- brane of the intestinal tube, objected to. (Brous- sais.) (Pract. Med. p. 80.) treatment. Treatment divided into that which is proper during the paroxysm, and that which is to be used in the intermission. INTERMITTING fevers. 39 The former is palliative, the latter curative. Treatment in the paroxysm. Cold stage: mild and warm diluent drinks. In debilitated and nervous subjects, external and internal stimulants, partic- ularly artificial heat. In vigorous subjects, how- ever, such practice is by no means proper. An emetic given in this stage, one of the best means to shorten its duration. Opium administered just before or soon after the accession of the pa- roxysm, often highly useful in moderating the fit. (Trotter.) Compression by the tourniquet, has been found useful to put a stop to this stage. (Kellie.) Its modus operandi explained. Treatment in the hot stage. The object is to moderate the violence of the febrile reaction, and to hasten the supervention of the sweating stage. The remedies employed for this purpose are: bleeding in cases of violent reaction, cool diluent drinks, and the usual antiphlogistic remedies. A draught of cold water, when the skin is very dry and hot, is both grateful and beneficial, predis- posing to perspiration. Emetics not proper in this stage. Excessive vomiting best checked by opium and the effervescing draught. Opium highly recommended in this stage, by Dr. Lind; injurious in intermittents of a marked phlogistic character; highly useful in case of feeble reac- tion. Not often necessary to use remediate treatment in this stage. [Pract. Med. p. 32.] Treatment during the Intermission. It is in this stage, that the radical cure of the disease is to be attempted. In prescribing with this view, attention must be paid to the four modifications described above. In inflammatory intermittents, the febrifuge tonics are not to be used, until the phlogistic 40 INTERMITTING FEVERS. state of the system has been reduced by a strict antiphlogistic treatmeut. (Pract. Med. p. 84.) In the congestive and malignant modiflcations, stimulants and tonics must be resorted to, early and freely. (Pract. Med. p. 75.) In the gastric modiflcation, emetics and cathartics are important preliminary remedies. Cinchona—the most efficacious tonic febrifuge we possess—must be employed during the apyrexia. Not to be employed, where a phlogistic diathesis prevails—that is, where the pulse is tense and quick, with a feeling of general uneasiness, head- ache, dry and warm skin, are present in the intermission: in such case, antiphlogistic mea- sures must be premised. The bark to be prompt- ly and largely given, in cases of great weakness, or in such as are of a malignant character. Au- thors express contradictory opinions, with regard to the necessity of purgatives and emetics, as measures preparatory to the use of the cinchona. They are very generally useful, and should be premised; not always indispensable, however— more essential in the young and plethoric, than in the infirm and aged. The cinchona has no peculiar tendency, as was once, and by some is still supposed, to produce visceral indurations; these are the consequences of the improper use of the bark—in other words, of its employment in a prominent phlogistic state of the system— other tonics will do the same. The existence of visceral obstructions form an objection to the use of the bark; a mild mercurial course must be pre- mised—or the bark may be given in conjunction with mercury. From an ounce to an ounce and a half, will in general suffice for a cure—when it purges, give opium or kino. When much acid- ity exists iu the primae viai, combine it with an alkali. The bark often advantageously combined INTERMITTING FEVERS. 41 with aromatics, as serpenlaria, cloves, calamus aromaticus, black pepper, capsicum, &c, &c. Sulphate of Quinine, a most valuable preparation of cinchona; given in doses of from one to three grains, every one or two hours; sometimes purges, for which opium is the proper remedy. A variety of other vegetable tonics have been recommended in this disease; as Augustura bark, cornus florida, Leriodendron tulipifera, aristologia serpentaria, oak bark, the various species of willow, horse chestnut, and the officinal tonic bitters. Coffee, recommended by Richter and Grindel. Tela aranearum, a useful remedy. The Muriate of Ammonia in combination with tonic bitters, highly useful, according to Richter, in agues attended with visceral obstructions. Arsenic, highly efficacious; best adapted to cases attended with rather a full, robust, and unirrita- ble habit—a moderately full, but soft and regu- lar pulse—and unaccompanied by local conges- tions. In debilitated, cachectic or scorbutic habits, often injurious; improper also in phthisical habits. Should be given in as large doses as the stomach will bear; apt to produce dropsical swellings. From ten to fifteen drops of Fowler's solution, with ten or fifteen drops of laudanum, every four hours. Prussiateofiron has been given with considerable success. Dose from five to eight grains every two hours, for an adult. Sulphate of zinc, an article of very considerable efficacy in the treatment of this disease. In com- bination with capsicum, I have found it almost as certain a remedy as the quinine. I give it according to this formula: B. Sulph. zinci, gr. x. Ptilv. capsici, Bij. Conserv. rosar. q. s. M. in pil. No xl. dividend. S. one every two hours. The power of the imagination over the system, is 42 REMITTING FEVER. often strikingly illustrated in its effects on this disease^ —the source of the occasional efficaey of all the various charms, amulets, &c, so frequently resorted to against this disease, by the ignorant and superstitious. Intermittents exceedingly apt to relapse; relapses particularly favored by exposure to a damp and cool air; by errors in diet; the depressing pas- sions, &c. Intermittents apt to give rise to secondary affec- tions, the most common of which are: oedema of the feet; enlargement and induration of the spleen and liver; jaundice, dropsy;—sometimes hemicrania, vertigo, epilepsy, and phthisis. See Practice of Med, vol.. 1. CHAPTER VII. REMITTING FEVER. Character. Fevers whose symptoms suffer regu- lar exacerbations and remissions, but no perfect intermissions. Symptoms: Symptoms of the forming stage, simi- lar to those of intermittents. When the disease is fully developed, there are pains in the head, back, and lower extremities; an icterode tinge of the eyes; nausea; sometimes bilious vomiting fulness and tension in the praecordia; pulse full, frequent, and rather soft; tongue foul, at first white, afterwards brownish; taste bitter. In the course of about twenty-four hours, a remission of these symptoms takes place; after a short re- mission, the febrile symptoms rise again; and REMITTING FEVER 43 after a certain period, again suffer more or less remission. This answers to the mild form of the disease. (See Pract. of Med. p. 97.) The type of remittents is generally the double ter- tian; sometimes the quotidian. The exacerba- tions of quotidian remittents commonly begin about nine or ten o'clock in the morning; those of tertians considerably later. Remittents sometimes assume a very violent and even malignant character: the febrile heat is in- tense; thirst excessive; head-ache, and pains in the loins, very violent: great anxiety of feeling; distressing sense of fulness in the epigastrium. In twenty-four hours, nearly a complete inter- mission ensues. A second and more violent paroxysm soon comes on; the eyes become red and watery; the epigastric distress is horrible; there is nausea, with constant retching or bilious vomiting. Another remission occurs, followed by a third exacerbation, which often terminates in death, or a favorable crisis. The disease sometimes assumes more of a chronic character; and in this case, great prostration ensues, with almost constant delirium; a quick, irregular, and frequent pulse: in some instances, the pulse be- comes almost natural—a sign of great danger. Besides the foregoing symptoms, the following occur, in violent cases of this form of fever: tongue clammy, fetid, black; eyes red, walery,or dry; urine brown, blackish, offensive—sometimes wholly suppressed; alvine discharges watery, red, black, or bloody; abdomen tympanitic, pe- techiae, haemorrhages. In the temperate climates, and in situations not abounding in materials for the production of mias- mata, remittents are generally mild and regular in their course. In proportion as we approach the tropical regions, we find the disease assuming a more violent and anomalous character. 44 REMITTING FEVER. Remote Cause. Marsh miasmata the principal cause of this form of fever; other causes may produce it—as worms, and other irritants, acting on the alimentary canal. Proximate Cause. Irritation, or sub-acute in- flammation of the mucous membrane of the intestinal tube, with prominent hepatic derange- ment. In some cases, prominent intestinal irritation is connected with an abundant secretion of bile; in others, the intestinal irritation is connected with great congestion and torpor of the liver, little or no bile being thrown into the bowels during the early period of the disease. To the former class of re- mittents, we may therefore apply the term Gastric; and to the latter that of Hepatic. Gastric Modification; characterised by: bitter or putrid taste; tongue covered with a thick yel- lowish slime, which by degrees becomes dry, cracked and blackish; disgust for every kind of footl; urine jumentose; distress and weight in the stomach; abdomen tense and tender; pain in the loins and knees; intense pain in the fore- head; distinct remissions and exacerbations.— (Pract. of Med. p. 100.) Hepatic Modification: the most rapid and dan- gerous form of the disease; characterised by: intense febrile heat during the exacerbations; delirium, fulness, tension, and pulsation in the right hypochondnum; tongue at first clean, great irritability of the stomach; continual vomiting of a glairy fluid; the skin becomes icteric,- towards the termination of the disease, the liver, in most instances, pours out an abundance of dark color- ed bile, which is evacuated by stool, and some- times by vomiting. The stools, in such instances, are black and pitchy. The diathesis of remittents always essentially in- flammatory, though in some violeat instances remitting fever. 45 much nervous depression and debility exists. Dr. Good calls these usthenic remittents—I pre- fer the term typhoid. Treatment. The indications are: 1. To mode- rate the action of the heart and arteries. 2. To remove the irritating contents of the bowels, and moderate intestinal irritation. 3. To restore the healthy functions of the liver. To answer these intentions, we employ: 1. Bleeding. Not often necessary, in the milder cases of our autumnal remittents. Indispensable when the pulse is full, vigor- ous, and hard, the skin very hot and dry, and the head-ache intense. 2. Purgatives. Mild mercurial purgatives, of primary importance. In mild cases, with little gastric irritability, an emeto-ca- thartic often useful in the commencement; inadmissible, however, in the higher grades of the disease. There are no remedies more useful in the treatment of remittents, than purgatives; and yet there are perhaps no other medicines so frequently employed to an injurious extent. Viohnt and irritating ca- thartics, when frequently administered, seldom fail to excite a degree of irritation in the mucous mem- brane of the alimentary canal, which but too often brings on a train of symptoms of the most danger- ous and fatal character. The thin watery stools, of a muddy or reddish color; the tympanitic state of the bowels; the abdominal tenderness; the suppres- sion of urine, &c, which are sometimes observed in the advanced stages of this disease, are generally the result of the imprudent employment of active cathartics. Although I would strenuously protest against the frequent employment of active cathar- tics during the course of remitting fever, I would by no means prescribe them wholly (as is done by Broussais) as remediate means in this form of fever. 5 46 remitting fever. In the commencement of the disease, one or two active purgatives are not only admissible, but, ac- cording to general experience, decidedly useful. Subsequently, however, the milder laxatives only ought to be employed; and these are indispensable, throughout the whole course of the disease.—(See Pract. of Med. p. 108.) Diaphoretics, &c. Nitre in combination with tartarised antimony and calomel, generally use- ful in the early stage of mild remittents; impro- per where there is great irritability of the sto- mach; injurious, also, when it excites much purging. The saline effervescing draught an excellent medicine; spiritus mindereri also use- ful; these two latter articles, particularly useful to allay gastric irritability. Calomel. An important remedy in remitting fevers. In the commencement given with a view both to its purgative and constitutional ef- fects; should be early and regularly given, until its specific operation becomes manifest; never to be continued until ptyalism comes on; strong mercurial excitement, injurious. In the ad- vanced periods of the disease, the mercurial influence generally detrimental. In the high or malignant grades of this disease —that which I have termed hepatic, from the en- gorged and inactive state of the hepatic system —emetics, emeto-cathartics, and strong purga- tives, useful in the commencement of the milder forms of the disease, are altogether inadmissible, The first object is to allay gastric irritability, which is generally very great. For this purpose, blood-letting is the most important measure, sinapisms to the region of the stomach, are good; a draught of cold water has been recommended; the warm bath after venesection; potio Riverii. YELLOW FEVER. 47 When the irritability of the stomach is in some degree subdued, Calomel is an important re- medy; it should be given in doses of from ten to twenty grains every four or five hours, until the evacuations become bilious. If the calomel do not prove purgative, mild laxatives must be occasionally given with it. Two or three alvine evacuations daily are indispensable, so soon as the liver has been excited to action by the calo- mel. Nitre, and the anlimonial preparations, are objectionable. Acidulated drinks are salu- tary. Physicians do not agree with regard to the propriety of using tonics during the remis- sions. Lind, Clark, Balfour, and others, strenu- ously contend for the vigorous employment of bark. Johnson, Burnet, and others, condemn this practice as pernicious. (Pract. of Med. 112.) My own views on this subject are, that the cinchona may be used with advantage during the remission, when there are no violent visceral congestions, and where the liver has resumed its proper action. As long, however, as the liver remains engorged and inactive, the employment of the bark can seldom fail to do injury. After the bile makes its appearance in the alvine evacuations, and a complete remission occurs, the liberal use of the sulphate of quinine will generally prove decidedly beneficial. YELLOW FEVER. Synonymes. Typhus Icterodes; Maladie de Siam; Bulam Fever; Vomito Prieto; Causes. Symptoms. First stage: faintness, giddiness, slight chills; then sudden evolution of intense febrile reaction, with severe pain in the head, inflamed eyes; intolerance of light; dry and burning skin; great thirst: pain in the loins and lower extremi- ties; tongue covered with a whitish mucus, or 48 YELLOW FEVER. but little altered from its healthy aspect; nausea and vomiting; transient and partial sweats. This stage lasts from twenty-four to sixty-hours. The disease sometimes commences with sudden loss of muscular power, and depression of nervous energy—the patient falling down as if stunned by a blow. Second Stage. With the exception of vomiting, all the symptoms abate; the pulse sinks to the natural standard, the heat of the skin becomes reduced, and the patient expresses himself much relieved. The vomiting however continues, the fluid ejected containing membranous flocculi; the desire for cold water is urgent, but when swallowed, is immediately rejected; the albu- ginia, and the skin of the neck and breast, ac- quire a yellow tinge. This stage lasts from twelve to thirty-six or forty-eight hours. Third stage. Pulse sinks; frequent and forcible vomiting; matter thrown up of a black color, resembling coffee-grounds suspended in a glairy fluid; an acrid or burning sensation in the stomach; diarrhoea of green or black matter; whole surface of a dirty yellow;* hemorrhages violent; delirium; hiccough, coma, insensibility, convulsions, death. " Soreness in the oesophagus; heat and acrid sensa- tion in the stomach; urgent thirst; hunger; violent delirium; despondency; enlargement of the blood- vessels and red-yellow color of the white of the eye, either singly or collectively, indicate extreme dan- ger." (Johnson.) Appearances on dissection. A black viscid fluid in the stomach; mucous membrane of this organ inflamed, and covered with gangrenous spots; * Many cases are not attended by this yellow hoe of the Bkin. YELLOW FEVER. 49 sometimes large portions sphacelated; small in- testines inflamed; colon generally sound, but often contracted; concave surface of liver in- flamed. Cause. The effluvium generated by animal and vegetable matters, in a state of putrefactive de- composition, its common remote cause—hence its almost continued prevalence in the marshy districts of intertropical regions. This opinion is disputed by many; but a great ma- jority of those whose knowledge on this point is derived from personal observation, maintain its cor- rectness. (Pract. of Med. p. 118.) Europeans arriving in hot climates, where the dis- sease is endemic, almost exclusively obnoxious to it. Persons having once had the disease, lose in some degree their susceptibility to a subse- quent attack. The influence of the remote cause is promoted by intemperance, excessive fatigue in the sun; ex- posure to the damp and cool night air, &c. Not contagious. Many assert that under certain circumstances, this disease is not contagious:— some maintain its unconditional and essentially contagious character. Black Vomit: not bilious matter;—appears to pro- ceed from sanguineous transudation in the sto- mach. The liver is torpid and congested, the biliary secretion being deficient. The yellow color of the skin is probably the result of a vica- rious secretion of a bilious matter into the sub- cutaneous texture. Different opinions on this subject. (Pract. Med. p. 117.) Treatment. Much diversity of sentiment in relation to the treatment of this disease. It appears, however, that the weight of good au- 5* 50 CONTINUED FEVER. thority is in favor of: full bleeding; mercurial purgatives; cold affusions, and applications to the head; the free use of mild diaphoretic or acidulated drinks—in the first period of the di- sease. Prompt and decisive bleeding is particu- larly beneficial in the commencement of violent cases, where the pulse is full and hard. In the milder cases, it may commonly be advantage- ously omitted. In the second stage, mild aperients; diaphoretic and cooling drinks; enemata; calomel with a view to its constitutional and aperient effects; cool affusions; with tonics and stimulants, if the pulse becomes feeble. In the third stage, stimulants and tonics; enemata; mild drinks. The usual saline diaphoretics are of little or no ser- vice, in this form of fever. The vigorous em- ployment of cinchona, or quinine, is strongly recommended by some, during the remissions. CHAPTER VIII. CONTINUED FEVER. Continued fevers are either: Sthenic, or Asthenic. The former are diseases with irritated vascular excitement—the vital energies being unimpair- ed or increased; these are usually called in- flammatory, or fevers with a phlogistic diathesis. INFLAMMATORY FEVER. 51 The latter are diseases with irritated vascular ex- citement, and an impaired state of the vital energies; these are the typhous fevers. (See Pract. of Med. p. 125.) INFLAMMATORY FEVER. Synonymes. Ardent fever; febris irritativa; synocha; febris vasorum. Character. Vascular excitement vigorous; pulse full, hard, and strong; heat of the skin intense; urine scanty and high colored: thirst great; eyes red, incapable of bearing the light; pulsating pain in the head; sensorial powers little affected. This form of fever is seldom introduced by a long train of premonitory symptoms; and in this, it differs essentially from typhus. The heat of the surface, of the kind called burning. Delirium not a common symptom. The pulse seldom beats more than 110 in a minute. The blood, when drawn, separates rapidly into its consti- tuent parts—the crassamentum contracting into a firm mass, on the top of which a yellowish mass of fibrine collects, forming what is termed the buffy coat, or inflammatory crust. (Pract. of Med. p. 129.) A somewhat similar covering is sometimes formed on the blood of typhous patients. The inflamma- tory buff has a uniformly yellowish white appear- ance. That which is sometimes seen on the blood of typhous patients, presents an iridescent appear- ance—reflecting the colors of the rainbow, when ■ held in certain positions. It is also much more brittle in its texture, than the former. [Richter.] Inflammatory fever never very protracted in its course; generally terminates in some manifest critical discharge; haemorrhage from the nose, 52 INFLAMMATORY fever. and increased flow of sweat the most common. Most apt to occur in persons of robust and vigo- rous constitutions, and between the ages of twen- ty and forty. Cause. The most common causes are: Atmos- pheric vicissitudes; violent passions; wounds and other injuries; a peculiar atmospheric consti- tution. Sudden suppression of perspiration by cold, is however the most common sporadic cause. Hence, inflammatory fevers most preva- lent in cold and variable climates, or during the spring of temperate latitudes; more prevalent also in elevated, dry, and sandy situations, than in localities of an opposite character. (Pract. of Med. p. 140.) Diagnosis between sthenic and asthenic fevers sometimes very difficult. The constitution and habits of the patient, the na- ture of the predisposing and exciting causes, will aid us in the diagnosis. In very doubtful cases, we must have recourse to the indices ex nocen- tibus etjuvantibus—the indications drawn from the effects of immediate agents. Prognosis. Simple inflammatory fever, the least dangerous variety of continued fevers; when at- tended with visceral 'inflammation, dangerous; the danger being proportionate to the violence of the local inflammation, and the importance of the organ inflamed. When protracted it is apt to assume a typhoid character. A sudden and copious discharge of limpid urine, or thin watery alvine discharges, are unfavorable. Slight hae- morrhage from the nose, a moist and soft skin, pale and turbid urine, are favorable signs. De- lirium not generally a bad sign. Treatment. The principal indications are: to INFLAMMATORY fever. 53 moderate the action of the heart and arteries, and to restore the healthy functions of the cutaneous exhalents. The remediate measures are [Pract. of Med. p. 140.] Blood-letting: this is the most important remedy. It should be early employed, and to the extent of producing a decided impression on the system. One decisive bleeding will do more good than double the same quantity of blood drawn at sev- eral smaller bleedings. To produce a proper im- pression, without too great an expenditure of blood, the bleeding should be from a large orifice. Repeated small bleediugs, during the course of a fever, are more apt to prostrate the system, than the same quantity of blood drawn at one or two bleedings in the beginning. The pulse must be our principal guide, as to the quantity and repeti- tion of bleeding. The inflammatory character of the blood, generally, an indication of the further necessity of bleeding. This indication cannot always be relied on—it is fallacious in rheuma- tism in which the blood will often exhibit the buffy coat, after bleeding has been carried to the utmost allowable extent. Cathartics. Useful not only by evacuating the ir- ritating contents of the bowels, but also by their direct depletory effects. The saline cathartics are the best; besides their evacuating effects, they have an antiphlogistic operation, analogous to nitre. Violent and very frequent catharsis, in- jurious. Emetics; seldom proper in inflammatory fevers. Diaphoretics are important remedies in this variety of fever. Of these, nitre and antimony are the most valuable—they are best given in combina- tion; 10 grains of nitre with 1-10 of tart. ant. 54 INFLAMMATORY FEVER. every hour or two. When the bowels are tor- pid, a grain or two of calomel may be added. Care must however be taken, not to continue the calomel so as to produce ptyalism—this effect could not fail to do harm. When the nitre excites gastric pain and watery purging, a few grains of pulv. ipecac, compos, may be advantageously combined with it. These effects are also lessened by giving the nitre in some mucilage. Antimony, peculiarly beneficial in febrile diseases; independent of its diaphoretic effects, it has a di- rect sedative operation; it appears, also, to act as an alterative, that is, to change the action of the capillary system generally. Its good effects in fe- vers are independent of the nausea which it is apt to create. Cullen, however, was of a different opinion. The Italians employ it in large doses, as a contra stimulant; in other words as a se- dative. Other diaphoretics employed in sthenic fever, viz. the saline effervescing draught; spiritus mindereri; muriate of ammonia; sweet spirits of nitre. These are useful, after the febrile excitement has been somewhat subdued. During the whole course, an antiphlogistic regimen must be rigidly observed. The antiphlogistic plan of treatment consists not only in the application of such remedies as are calculated to reduce the actions of the system, but also in the careful removal of every thing which has a tendency to irritate or excite in an inordinate de- gree. In inflammatory fevers, the irritability of the nervous and sanguiferous systems is morbidly in- creased; and hence, even the ordinary stimulants of light, sound food, &c, become a source of increased irritated action. The influence of these may there- fore be avoided, as much as circumstances will allow. CATARRHAL FEVER. 55 Catarrhal Fever. Character. A sthenic fever, with prominent irrita- tion of the mucous membrane of the respiratory passages. Symptoms. At first, lassitude and slight chills; then more or less febrile reaction—attended with a frequent, quick, and somewhat tense pulse; se- vere pain in the head, face, or jaws; sneezing, dry cough, and hoarseness; a watery discharge from the eyes and nose; eyes red and painful; transient stitches through the chest; often rheumatic pains in the back and extremities. There are consider- able remissions in the morning, and exacerbations in the evening. During the first three or four days, the urine is high colored and free from sedi- ment. About the fourth or fifth day, the febrile symptoms begin to decline; the urine then be- comes pale and turbid, and the skin uniformly moist; the discharge from the nose and the bron- chia becomes thicker and yellowish. The existence of the latter cause is inferred from the circumstance of this form of fever occasionally pre- vailing epidemically—extending itself over whole continents, and even passing from one continent to another. Causes. Atmospheric vicissitudes—a specific mias- ma, or a peculiar constitution of the atmosphere. Prognosis. Not in general a dangerous form of fe- ver; most dangerous in infants and in very old people; apt to excite phthisis in those who are predisposed to it. Proximate cause. Irritation and inflammation in the mucous membrane lining the respiratory pas- sages, with disordered action of the cutaneous ca- pillaries. 56 TYPHUS. Treatment. Moderate bleeding, in the young and robust; in the aged and in infants generally unne- cessary, and often improper. Mild laxatives use- ful in all cases. Mild diaphoretic drinks, such as infusion of eupatorium, sage, camomile, &c. together with pulvis antimonialis, spiritus minde- reri, or spir. nit. dnlc. are important remedies. Blisters to the breast, when the pneumonic symp- toms are severe. Mild expectorants, to relieve the cough. TYPHUS. Typhus is by no means so common a disease as is generally supposed. The term Typhous is fre- quently applied to fevers essentially distinct from typhus. Synochous and catarrhal fevers are often improperly denominated typhous. Typhus divided into four period.s, viz, the forming stage, the stage of invasion, the stage of excite- ment, and the stage of collapse. Symptoms—Of the forming stage. Lassitude, gid- diness, and dull pain in the head; a peculiar un- easy sensation in the stomach, nausea, and some- times vomiting; want of appetite; thirst, pale and shrunken countenance; tremor of the hands; eyes. dull and heavy; muscular debility. This stage lasts from three to seven days. Stage of invasion. Slight chills, alternated with flushes of heat; tongue whitish or clammy; entire disgust of food; nausea and vomiting; a sense of weight and anxiety in the praecordium. This stage lasts from six to twenty-four hours. Stage of Excitement. Face full and flushed; pulse full, somewhat resisting, and accelerated; skin dry and warm; lips parched; thirst urgent, bowels TYPHUS. 57 constipated; eyes red and watery; slight and tran- sient delirium; vigilance; obtuseness of hearing; weight and oppression in the chest; tenderness and fulness in the hypochondria; catarrhal and peripneumonic symptoms; mind-about the third day, confused, as if stunned; great reluctance to mental and corporeal action. About the fourth day, a red miliary eruption often makes its ap- pearance. Hildebrand regards this as an essential exantheme of this disease. The voice is at first rather plaintive, but in the advanced periods of bad cases, it becomes guttural, and " at last, truly sepulchral." The body exhales a peculiar odor in this disease. This stage lasts usually about seven days; at the end of this period, it terminates in the Stage of Collapse. This stage is characterised by: great prostration of muscular power; torpor of the sensorial functions; a very frequent and fee- ble pulse; tongue brown, dry, at last black; in- crustation of the teeth with a blackish matter; short and feeble respiration; difficult deglutition; almost constant delirium; coma; tongue tremu- lous, and put out with difficulty; subsultus tendi- num; hiccough; heat of the skin intense and acrid; unequal distribution of the animal tempe- rature; diarrhoea, with pain in the bowels, in the latter periods of severe cases; urine pale; tympa- nitic bowels; sometimes petechias.- The foregoing sketch applies to typhus in its regu- lar and simple form. In this form, there are manifest morning remissions, and evening exac- erbations. Typhus is subject to various import- ant modifications. In some instances, local in- flammations supervene, forming what Dr. Armstrong calls 6 58 TYPHUS. Inflammatory Typhus. The organs most liable to become the seat of inflammation are, the lungs, the brain, the intestinal canal, the liver, and the peritoneum.—The mucous membrane of the alimentary canal and the arachnoid of the brain, the most commonly affected. The theo- ries of Broussais and Clutterbuck referred to. In some instances, the stage of excitement does not become developed, the stage of oppression con- tinuing throughout the whole course of the dis- ease. This variety constitutes Dr. Armstrong's Congestive form of typhus. This modification is characterised by: a want of reaction; great pros- tration and sinking, from the commencement; deep pain in the head, and in vertigo; face pale and dingy; respiration anxious and oppressed; pulse small and variable; skin cool, damp, and relaxed; countenance bewildered or vacant; eyes dull, watery, and red, or glairy and staring, with- out redness; bowels at first constipated—towards the conclusion, copious involuntary stools; tongue pale and tremulous, becoming at last brown and rough; petechias; passive haemorrhages; coma; sometimes, from the beginning, complete torpor and insensibility. Dr. Armstrong's opinion that the depressed and prostrated state of the system depends on inter- nal venous congestion, refuted. The internal congestions are most probably the consequence, and not the cause, of the impaired or depressed condition of the vital energies. When the remote cause of typhus acts with great intensity upon the system, the vital powers are suddenly prostrated; in consequence of which, the heart and the capillary system act feebly—the blood recoils from the surface to the central vessels, and gives rise to internal congestions, which the enfeebled TYPHUS. 59 heart is now unable to overcome. (Pract. of Med. p. 151.) Causes of Typhus. Typhus almost peculiar to the cold seasons of the temperate climates. Smith, Femar, and Wedekind, have seen it dur- ing the hottest weather in summer. Propagated by a specific contagion: evidence adduced in support of this assertion. Typhus occasionally originated by other causes than contagion—defi- cient and unwholesome food, and the contami- nated air of confined and crowded apartments, the most common causes of this kind. Upon the subject of the origin and mode of propaga- tion of this disease, physicians are by no means unanimous. Some regard typhus as always and essentially a coutagious disease, while others deny that it is ever communicated in this manner. The weight of good testimony is in favor of the occa- sional generation of the disease, by causes entirely distinct from contagion. When once generated, it may, and frequently does, spread from the sick to the healthy, in the manner of a contagion. Prognosis. Free and spontaneous vomiting, in the beginning, particularly when it relieves the giddiness, generally indicates a mild course of the disease. Haemorrhage from the nose, about the seventh day, is favorable. Very manifest remis- sions in the morning, are always a good sign. Moderate diarrhoea, during the first days, is fa- vorable; but when it occurs in the latter periods of the disease, it is a very bad sign. Great thirst, in the stage of collapse, is favorable; so also is a moist tongue, in this stage. The absence of im- portant or violent local inflammations, always a good sign. Diminution of the frequency of the pulse, and of the acrid heat of the skin, is favor- able. Among the symptoms which are particu- larly unfavorable, are: great change of the ex- 60 TYPHUS. pression of the countenance, in the beginning of the disease; entire absence of thirst; constant and violent delirium; early petechias; strong peri- pneumonic symptoms; swelling of the parotids. The most dangerous signs, in the last stage, are: blindness, involuntary flow of tears; difficult de- glutition; palsy of the tongue; constant low mur- muring; and entire abandonment of himself; a very frequent and small pulse; pain in the region of the bladder; tenderness and tumefaction of the abdomen: floccitatio; continued motion of the hands and fingers; diarrhoea; insensibility to the vesicating effects of cantharides; hiccough; aph- thae in the mouth; suppression of urine, &c. (Pract. of Med. p. 159.) Treatment. The first object is to remove as much as possible the remote cause, or to lessen its activity. With this view, the patient is to be removed from the confined and contaminated air in which the disease was contracted; or if this cannot be done, the apartment in which he lies must be freely ventilated. Diversity of opinion, in relation to the treatment of typhus. Many physicians maintain, that no remedial treatment is adequate to interrupt the course of the disease, when once completely formed. (Smith, Hildebrand.) This I believe to be an erroneous opinion. Attention to the several stages of the disease, all-important in its remediate treatment. In the forming stage, the indications are: to over- come the torpor of the external capillaries; to determine the circulation to the surface; and in- terrupt the morbid sympathetic actions through- out the system. For this purpose, emetics axe highly serviceable; given soon after the attack of TYPHUS. 61 the disease, they will often iuterrupt its course. After the operation of the emetic, Mild purgatives should be employed. . Two or three alvine evacuations should be procured daily. Diaphoretic ptisans, beneficial in this and the sub- sequent stage; such as infusions of eupatorium, catnip, sage, &c. Calomel: In the early periods of the disease, this article is often decidedly useful. Slight mercu- rial influence, the most effectual means of arrest- ing typhus in its early stage; two grains of calo- mel may be given every four hours, until the gums become slightly inflamed. The constitu- tional influence of mercury generally pernicious after the disease is fully developed—its benefits being restricted to the first five or six days. Ca- lomel no less beneficial, in the early stages of congestive fevers. (Armstrong.) It has a pow- erful tendency to equalise the circulation; it raises the pulse, restores warmth to the skin, and increases the general energy, in such cases. In the stage of excitement, a more or less anti- phlogistic treatment becomes necessary. Mild cathartics particularly useful in this stage—they moderate at once the general excitement, the heat of the skin, and the force of the pulse. Cold Affusions. When the skin is hot and dry, in this stage of typhus, the affusion of cold water is often highly beneficial. As the stage of col- lapse approaches, the temperature of the water should be raised. Cold affusions are improper, when the skin is below the natural temperature, and a sense of chilliness is present, or when there is profuse perspiration. Common salt may be advantageously added to the water, particu- 6* 62 TYPHUS. larly when there is much prostration. When the heat of the body is unequally distribu ed, neither cold nor tepid affusions are proper: local inflammations also form an objection to cold affusions. In such cases, sponging the body with tepid water will sometimes do good. Diaphoretics,of the refrigerant c/cm,useful during the stage of excitement. Bleeding, very rarely called for, in cases of simple typhus. Stage of Collapse. In this stage, stimulants and tonics are the appropriate remedies. Wine, ser- pentaria, calamus aromatics, ammonia, opium, aether, phosphorus, camphor, and musk, are the most useful. Of these, wine, ammonia, cam- phor, and opium, are the best. When stimulants render the pulse fuller and slower, and the skin moist and cooler, they may be continued with confidence; but when the pulse becomes more frequent and corded, the countenance flushed, with an increase of restlessness and delirium, under their use, they are doing injury, and must be discontinued. Camphor particularly service- able, where there is much delirium; combined with nitre and calomel, useful even in an earlier period, when the disease is complicated with pe- ripneumonic symptoms. Small doses of opium, with infusion of serpentaria, beneficial in pneu- monic typhoides. Musk said to be particularly useful, in typhus of habitual drunkards. Opium serviceable, when in the last stage, where there is much restlessness, delirium, and other symp- toms of nervous irritation; combined with calo- mel and chalk, excellent to check the diarrhoea, which sometimes supervenes in this stage. Distinction between true and false debility. In the TYPHUS. 63 former, there is an actual impairment of the vital powers; in the latter, the powers of the system are oppressed, generally, in consequence of intes- tinal irritation. False debility sometimes occurs before the supervention of the stage of collapse; if, through mistake of its nature, stimulants are given, injury will be done. The diagnosis be- tween true and false debility. In false debility, or prostration from intestinal irritation, there are, generally, much jactitation; flushed countenance; eyes suffused; extremities cold; pulse irregular and very small; hurried and anxious respiration; stupor; little or no delirium: it generally comes on suddenly. In debility, or sinking from an impaired state of the vital powers, the prostration usually comes on gradually; delirium is almost constant: skin hot, the heat being of the acrid kind, (color mordax;) the countenance is sunken and inanimate, with subsultus tendinum, &c. Observations on the use of laxatives, in the stage of collapse. They are often highly serviceable. They should be given in conjunction with stimu- lants, such as ammonia, wine, alcohol, &c. One or two stools should be procured daily. Cinchona not in general of much use; when in the latter stage, the tongue and skin are dry, and there is much delirium, coma, and subsultus ten- dinum, the bark is improper. Blisters seldom serviceable, in simple typhus. Diet. Solid food injurious: farinaceous and muci- laginous substances, the only nutriments admissi- ble. Barley water, and thin oat-meal gruel, should be freely allowed, in the stage of collapse. In typhus, complicated with local inflammation, bleeding, in the second stage, is often indispensa- ble: it must be early employed; delayed beyond 64 TYPHUS. the thirty-sixth hour after the beginning of the inflammation, it will most commonly do harm.— Sufficient blood should be drawn at once, to make a decided impression on the system. Small bleedings, however frequently repeated, afford no permanent advantage. Cupping or leeching may be beneficially employed, when general bleeding is contra-indicated. Calomel with Opium, a valuable remedy after proper depletion, in typhus with pneumonic sys- tems. One grain of each may be given every four hours. This remedy is hurtful, when the inflammation is seated in the brain. In prescribing depletory measures in typhus, even when connected with inflammation, it should be kept in mind, that there is always lurking at the bottom a radical tendency to a state of exhaustion or prostration. Typhus in which reaction does not take place, or Congestive Typhus. Bleeding recommended by Armstrong and others. Objections stated against this practice, and reasons given in favor of the employment of stimulating frictions, warm ap- plications to the external surface, and warm and gently stimulating drinks. Applications of this kind not only cause a determi- nation to the surface, and thereby relieve the heart and arteries, but they also tend to invigorate and support the general energies of the system, by the stimulus they impart to the nervous extremities of the surface. Blisters, purgatives, calomel, and opium, are impor- tant remedies in this modification of the disease. Further observations on the beneficial influence of calomel, in congestive stales of fever. While this remedy is given, with a view both to its pur- gative and constitutional effects, warm and stimu- inflammation in general. 65 lating applications should be made externally. A blister to the epigastrium will often do much ser- vice in such cases. (Armstrong.) CHAPTER IX. INFLAMMATION IN GENERAL. Phenomena. Pain, increased heat, redness, and swelling. Pract. Med. p. 17 2. 1. Pain. Not always, though generally, present; generally, the looser the instructure, the less pain; sometimes absent, in peripneumonia, gastritis, pericarditis, &c; inflammatory pain always in- creased on pressure, and may be thus distin- guished from spasmodic pain. The nature, of the structure inflamed modifies the character of the pain. The violence of the general febrile reaction, proportionate to the intensity of the pain. 2. Increased heat. Not always present; actual degree of heat never raised above 98°. The sen- sation of heat depends on the altered state of the sensibility of the inflamed part. 3. Redness. Almost an invariable phenomenon of inflammation; arises from the intromission of blood into the serous capillaries; generally re- mains after death; redness, by itself, no certain sign of previous inflammation; the serous capil- laries may become injected with red blood in ar- ticulo mortis, although sound before; impor- 66 inflammation in general. tance of this knowledge, in autopsic examina- tions. 4. Swelling. The effort of effusion into the sur- rounding cellular tissue; the firmer the structure, the less swelling. Inflammation is located in the capillary system. The more abundant the capillaries of a part, the more apt is it to become inflamed. The mucous, serous, cellular, and dermoid systems, being very vascular, are very subject to inflammation; the contrary obtains with the osseous, the cartilagi- nous, and the tendinous structures. (Bichat.) Aetiology. Inflammation may be produced—1. By the direct operation of irritants on a part. 2. By the indirect operation of irritants on parts, through the medium of the nervous system. 3. By general irritated vascular excitement. 4. By metastasis. Whatever be the exciting cause of inflammation, the following changes take place in progress of its evolution: viz, irritation; then alteration of the vital properties; and finally, an afflux of blood to the part. These changes often succeed each other so rapidly, that they seem to arise simultaneously. A change of the vital proper- ties is essential to inflammation; preternatural determination to a part, without altered sensibi- lity and contractility, constitutes congestion, or local plethora—not inflammation. (Bichat.) Are the capillaries of an inflamed part in a state of debility, and is the velocity of the blood circula- ting in them diminished—or, are they in a state of increased action? Vacca, Lubbock, Allan Phillip, and Hastings, have written in support of the former opinion; but the subject is still sub judice. inflammation in general. 67 My own view on this subject is, that the inflamed capillaries ought to be regarded as being in a state of irritated excitement; and that this irritated condi- tion may be connected either with an increased or with decreased power of action. In this respect, lccal inflammation corresponds with that general irritated vascular excitement, which constitutes fever. The heart and arteries are in a state of irri- tated action, with increased power of acting in syno- cha. In typhus, there is also general irritated excite- ment; but it is connected with a fundamental debi- lity of the vital powers. There is, therefore, accord- ing to my apprehension, a typhous and a synochal state of inflammation; and this corresponds with the results we obtain from remedial applications. May we not explain these different diatheses of in- flammation, by the greater or less degree of organic injury sustained by the nervous filaments of the in- flamed capillaries'? When a part is irritated, so as merely to exhalt the sensibility of the capillaries, by exciting their nervous texture, the consequent in- flammation will probably be one of increased capil- lary 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, the inflammation resulting from its action will, I conceive, be characterised by debi- lity, and stimulating applications, as if the case in scalds and burns. Termination of inflammation. These are qua- druple:—(Prac. of Med. p. 175.) 1. Resolution. Inflammation is said to terminate in resolution, when it declines and disappears without any structural lesion, or perceptible dis- charge. Resolution is more prompt, in propor- tion as the organ affected possesses a higher de- gree of vitality; in the serous membranes, the progress of inflammation is particularly rapid. (Bichat.) Resolution is often accompanied by an increase of the natural secretions of the part: this is particularly noticed in the mucous and 68 inflammation in general. serous membranes; also, in rheumatic inflamma- tion. 2. Effusion. The effusion may be blood, lymph, or serum. The termination by effusion of blood, most common in the mucous membranes; effu- sions of lymph and serum, almost peculiar to the serous membranes—the former fluid forms a bond of union between the serous membranes. Such adhesions never occur in the mucous mem- branes. Serum seldom abundantly exhaled, un- til the inflammation has assumed a chronic or sub-acute character. Dropsies are the conse- quence of this mode of termination. Effusion of lymph into the substance of the solid viscera, result in induration. 3. Suppuration. The cellular, serous, and mu- cous tissues, are most prone to this termination; the bones and tendons never suppurate. The mode of suppuration different in the different structures; in the mucous membranes, it is a morbid secretion, the pus having a whitish, cream- like appearance. In the serous membranes, pus is formed by a kind of exhalation, and is a thin whitish, or whey-like fluid, sometimes mixed with flakes. In the cellular tissue, pus collects in circumscribed cavities, called abscesses, and is of thick and uniform consistence and pale yel- low color, exhibiting to the microscope minute globules suspended in a serous fluid. Symptoms denoting the occurrence of suppuration, in the inflammation of external organs: a sensation of weight in the inflamed part; change from the acute to a dull throbbing pain; rigors; pulse losing its tension and hardness, and becoming soft and full; night sweats, and other symptoms of hectic. inflammation in general. 69 4. Gangrene. Never occurs in the cartilages, nerves, or bones. The cellular, mucous, and se- rous tissues, are most prone to it; more common in the peritoneum, than in any of the other se- rous membranes; of the mucous membranes, that lining the alimentary canal is most subject to it. The occurrence of gangrene is denoted by, sudden cessation of pain; sinking pulse; cold extre- mities; cold sweat; delirium; and cadaverous countenance. There exists in the different forms of inflammation, an " original disposition to terminate in one mode, rather than another: thus, in boil and whitlow, it is to suppurate; in carbuncle, to slough; and in mumps, to resolve: and this disposition is so strong, that it is very difficult to procure any other termination." Varieties of inflammation. Inflammation occur? under five prominent modifications, correspond- ing to the five elementary tissues—viz. the cel- lular membrane and parenchyma of the solid viscera; the serous membranes; the mucous mem- branes; the skin or dermoid tissue; and the fibrous membranes. 1. Inflammation of the cellular membrane, or phlegmonous inflammation. Charac- terised by, great swelling, throbbing pain, and by its mode of suppurating; the pus being collected in circumscribed cavities. Diffuse cellular inflammation. 2. Inflammation of the serous membranes, or serous inflammation. Pain very acute and lancinating—rapid in its course; no tumefaction; much sympathetic excitement of the general sanguiferous system, termi- nating in the exudation of coagnlable lymph or serum, or the secretion of a whey-like pus; adhesions are pecular to this variety 70 INFLAMMATION IN GENERAL. of inflammation; it rarely terminates in gan- grene. 3. Inflammation of the mucous membrane, or mucous inflammation. Almost always produced by sudden atmospheric vicissitudes, in consequence of the close sympathy which subsists between these membranes and the skin. Sometimes prevails epidemically.— Pain not very severe; unattended with swell- ing of the subjacent cellular tissue; concomi- tant fever not intense; never terminates with- out an increase of mucous secretion. No adhesions ever formed. 4. Inflammation of the skin, erysipelatous inflammation. Pain of the stinging or burning kind; spreading; forming vesicles; never suppurating in circumscribed cavities; dependent on a specific cause. 5. Inflammation of the fibrous membranes, or rheumatic inflammation. Pain intense and aching; does not terminate in abscess or suppuration; terminates by an exudation of a gelatinous matter; or by earthy depo- sitions; is wandering, accompanying fever always synochal; rarely proves fatal, except by metastasis to organs essential to life. Diagnosis of internal inflammations. The exis- tence of internal inflammation is ascertained by: the continuance of the pain; the appearances of the blood; the state of the general vascular ex- citement; the effects of external pressure; the effects of position; the character of the functional derangements; the temperature of the skin; and the nature of the exciting causes. PHRENITIS. 71 CHRONIC INFLAMMATION. Chronic Inflammation is generally, though not always, the consequence of acute inflammation. Doctrines concerning its nature. The effects of Chronic Inflammation—dropsical effusions, and tuberculated accretions in the se- rous membrane; phthisis, diarrhoea, dyspepsia and various other affections in the mucous mem- brane, &c. Treatment. The indications in the treatment of acute inflammation, are.— 1. To diminish the momentum of the general circulation; 2. To drive the blood from the inflamed part; 3. To alter the the action of the inflamed capillaries; and 4. To change the inflammatory condition of the blood. CHAPTER X. INFLAMMATION OF THE BRAIN. Encephalic Inflammation is divided into two va- rieties—viz. Phrenitis and Arachnitis. PHRENITIS. In Phrenitis, the substance of the brain, as well as its membranes, are involved in inflammation. Symptoms. Synocha; fixed and intense throbbing pain in the head; face full and flushed; eyes in- 72 ARACHNITIS. flamed; intolerance of light; hearing at first mor- bidly acute, at last almost complete deafness; furious delirium from the commencement, and constant wakefulness. Causes. Insolation. Distinguished from mere synocha, with high cerebral excitement, by the following circumstances. In phrenitis, there is always prominent derangement of the organs of sense—in synocha, hearing and vision are but little affected. In phrenilis, the internal func- tions are always much disturbed—in synocha, this is rarely the case. In synocha, the pulse is hard, full, frequent, and vibrating, from the beginning—in phrenitis, it does not become so until the inflammation is fully formed. Prognosis. Haemorrhage from the nose is favor- able—from the bowels, in the advanced stage, unfavorable; coma supervening to delirium is a fatal sign. Au/op.yic Phenomena. Flakes of coagulable lymph, pus, and serum between the membranes; some- times adhesions; abscesses in the substance of the brain; erosions of the dura mater. Treatment. Vigorously antiphlogistic. Prompt and decisive bleeding, both general and lo al; cold applications to the shaven scalp; cathartics; the refrigerant diaphoretics; blisters to the nape of the neck, after the febrile excitement has been moderated by depletion. The head should be kept in an elevated position, and the chamber dark, noiseless, and cool. Digitalis and nitre," after the disease has been in some degree sub- dued. (Pract. of Med. p. 257.) ARACHNITIS, OR HYDROCEPHALUS ACUTUS. This is a much more common form of encephalic ARACHNITIS. 73 inflammation than the preceding one. It has of late years been extensively investigated, by Martinet and Duchatelet, of Paris, whose pa- thological researches, in relation to it, are highly interesting and valuable. I treat of hydrocepha- lus and arachnitis under the same head; for it is now placed beyond all doubt, that the malady known and described under the name of hydro- cephalus, is neither more nor less than arachnoid inflammation. The term hydrocephalus is in- peed altogether inappropriate to the disease; for instead of directing the mind to the primary and essential affection, it has reference only to one of the occasional consequences of the disease. (Pract. of Med. p. 262.) Symptoms. Often very gradual in its approach. In this case, there are transient pains in the head and abdomen; the patient is dull, fretful, restless, and discontented; countenance pale, with an oc- casional flush on the cheek; the brows contracted; appetite variable; bowels torpid, or mucous diar- rhoea; starting and grinding the teeth during sleep. After these symptoms have continued for an indefinite time, those which characterise the disease in its full development come on: these are—severe pain in the head, nausea and vomit- ing; deep sighing, occasional somnolency, and slight delirium; very dilated or contracted pupils; an expression of surprise and stupor in the coun- tenance; slight redness of the conjunctiva; para- lysis of the upper eye lids; squinting; eyes turned up, so as to hide the cornea under the upper lid; towards the last, constant somnolency, interrupted by spells of great anxiety and rest- lessness, or fits of violent and frightful scream- ing, paralysis of one side; convulsions; death. The patient can seldom be induced to utter more 7* 74 ARACHNITIS. than monosyllables. The pulse is at first irri- tated, frequent, and tense; when somnolency comes on, it becomes slower; towards the termi- nation, it again becomes very frequent. The disease is sometimes ushered in by convul- sions. I have seen it come on without any fe- brile excitement, the countenance remaining pale, with cold hands, deep sighing, a peculiar expression of surprise, vomiting, and constipa- tion. It sometimes comes on in the shape of a remitting fever. After a few days languor and drooping, fever ensues, attended with head-ache, flushed countenance, tenderness of the abdomen, stupor during the exacerbations, the patient screaming and starting up in great alarm, great irritability of the stomach, obstinate constipation, &c. Predisposition. Hereditary, in some instances; the scrofulous diathesis predisposes to it. Exciting causes. External injuries; dentition; intestinal irritation; suppression of serous dis- charges of cutaneous eruptions, particularly about the head; frequently the consequence of cholera, whooping cough, measles, and scarlatina. Diagnosis. Arachnitis to be distinguished from infantile remittent, by the regularity of the remissions in the latter, and the character of the stools. In infantile remittents, the stools are foetid, and of a dark-brown or mud-like appear- ance—in arachnitis, they are dark-green and glairy. The connection between arachnitis and cholera infantum pointed out. Prognosis. Always highly dangerous; deep som- nolency, paralysis, blindness, strabismus, and convulsions, indicate a fatal termination. ARACHNITIS. 75 Aulopsic Phenomena. Commonly, general red- ness of the arachnoid membrane; sometimes it is opaque and thickened, with a purulent, sero- purulcnt, or sero-gelatinous effusion on the sur- face, more or less serous effusion into the ventri- cles, and between the lamina of the arachnoid. Treatment. The indications are.—1. To mode- rate the general febrile excitement; 2. To sub- due the local encephalic inflammatory affection of the brain; and 3. To remove those causes which tend to keep up a preternatural determi- nation to the brain. For this purpose are employed: Bleeding, copious and prompt, both general and local. The blood should be suffered to flow, until an approach to syncope is induced;—leech- ing on the crown of the head. (Duchatelet.) General always to be premised to local bleeding. Purgatives are of great importance. Calomel the best purgative, on account of the torpor of the liver in the early period of the disease. Where worms are suspected, spigelia and senna should be used. In cases depending on intestinal irritation; and the majority of cases in infancy are of this kind— violent purging is improper. Mild laxatives, how- ever, are "of the utmost importance. Where the disease has been brought on by external injuries to the head, or where the arachnoid inflammation is idiopathic, the more active purgatives may be em- ployed with advantage. Revulsive applications. Cold applications to the head; blisters, pediluvium; cupping. Blisters are usually applied to the shaven scalp—I prefer placing them behind the ears, or on the nape of the neck, while ice or other cold applications are 76 ERETHISM OF THE BRAIN. made to the scalp, and sinapisms laid on the soles of the feet. Mercury: with a view to its constitutional influ- ence, one of our most useful remedies in this disease. Percival, Dobson, Rush, Cheyne, and others, mention cases which yielded to it. Ja?nes's Powder. Dr. Stocker states, that this ar- ticle has a decided tendency to diminish the cir- culation to the head; and of the truth of this observation, I have had repeated evidence. It is best given in combination with calomel, in this disease. Dover's Powder. Drs. Brooke, Percival, Cheyne, and Crampton, speak highly of the efficacy of this article in hydrocephalus. In cases depending on intestinal irritation, after adequate depletion, it may sometimes prove serviceable. In the idio- pathic form of the disease, however, all opiates are injurious. Digitalis has been recommended: and from its tendency to lessen the action of the heart and arteries, it may undoubtedly be employed with occasional advantage. ERETHISM OF THE BRAIN. (Dr. Nicholl.*) Infants are subject to a morbid condition of the cerebral structures, which appears to consist in a highly irritable or sensitive state of the nervous centre; being unattended by inflammation, or increased momentum of blood in the cerebral vessels. I have frequently witnessed this affec- tion, and think it a subject of sufficient impor- * Practical Remarks on Disordered States of the Cerebral Struc- tures, occurring in infants. By Whillock Nicholl, M. D. &c &c London,1821. SOFTENING OF THE BRAIN. 77 tance and interest, to introduce it to the attention of the medical student. It is characterised by: wakefulness; irritable temper; retina very sensible to light; contracted pupils, much action of the limbs; head often moved from side to side, extreme fret fulness; frequent crying, without any apparent cause—the little patient being " soothed only by tossing it, by carrying it about, putting it to the breast, or letting it suck the cheek of the nurse, or its own fingers;" increased secretion of tears; bowels generally relaxed, without a dis- ordered state of the stools. When sleeping, the child often starts, and is readily awakened; when awake, it starts at the slightest noise, or on being slightly touched; often shrieks out, as if it were pricked with a pin; the fists are frequently clenched, the thumb being bent in, and the fore-arms bent upwards on the arms. Sometimes the child presents, for a short time, a state of opisthotonos " its legs being drawn up, and the head thrown backwards." In adults, this erethismal state of the brain shows itself by " irritability of temper," inability to bear the effects of the most trifling sounds, wakefulness, restlessness, febrile symptoms," &c. Subjects of a scrofulous diathesis are particularly predisposed to this morbid cerebral irritability. Causes: dentition; gastric irritation, from various causes; torpor of the liver, &c. Treatment. Exercise in the open air; small doses of ipecac, compos.; a mild nnirritatmg diet; leeches to the temples; lancing the gums; mild aperients and diuretics; pediluvium. SOFTENING OF THE BRAIN. This form of cerebral disease has of late been 78 SOFTENING OF THE BRAIN. abundantly noticed by the French pathologists. Recamier, Bayle, Cayol,Brichereau, Rostan,and Lallemand, have published numerous interesting observations, concerning its symptoms and pa- thology. The disease consists in a softening, or kind of liquefaction, of a portion of the brain, with vascular injection of the rest of its sub- stance. Rostan divides the disease into two pe- riods. The symptoms of the first period are: a fixed and violent pain in the head, often continuing for several months; vertigo; obluseness of the men- tal faculties, the memory being weak, and the ideas confused; questions are answered after long hesitation; dejection; querulousness; indiffe- rence to surrounding occurrences; drowsiness; tingling and numbness in the fingers; frequently perverted vision, and occasionally total blind- ness; dull hearing—sometimes very acute; fre- quently nausea and bilious vomiting; tenderness of the epigastrium; constipation; pulse variable, sometimes hard and full; occasionally there is delirium, with fever, and much agitation. The second period is characterised by a gradual or sudden paralysis of one limb, sometimes of half the body; consciousness and intellect remain; questions are answered with very great difficulty, the patient generally expressing his desires by automatic movements; sometimes perfect coma; death commonly follows in two or three days. The corpora striata and thalami opticorum, have been most frequently found the seats of this soft- ening. The inflammatory nature of this disease has been much doubted by some; but the facts and argu- ments adduced by Lallemand, render the opinion ACUTE GASTRITIS. 79 of its being of an inflammatory character ex- ceedingly probable. This writer thinks that the softening is " the effect of inflammation arrested in its course by death before purulent suppura- tion has had time to take place." Diagnosis. A contraction of the flexor muscles of the limb, is particularly characteristic of this dis- ease.—"Sometimes," says Lallemand, "this amounted to only 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." Contrary to what takes place in apoplexy, the mouth is drawn towards the paralysed side. Treatment. General and local bleeding; sina- pisms to the feet; cold applications to the head; cathartics; blisters to the back of the neck; calo- mel, with a view to its salivant effect. CHAPTER XI. ACUTE GASTRITIS. Symptoms. Burning and lancinating pain in the stomach; frequent vomiting, particularly on swallowing fluids; urgent desire for cold drink; constipation; fever, with a small, hard, and fre- quent pulse. After a draught of cold water, a temporary mitigation of the gastric pain occurs; difficulty of swallowing; disgust of warm drinks; great prostration of strength from the beginning. (Pract. of Med. p. 106.) 80 ACUTE GASTRITIS. Diagnosis. Distinguished from spasms and flatu- lent pains, by the following circumstances. In gastritis, the pulse is small and tetuse—in cramp, it is generally natural. In the former, there is violent and frequent vomiting—in the latter, this rarely occurs. Warm drinks excite instantane- ous vomiting, in gastritis—in spasm they do not. The pain of gastritis is continuous—that of spasm is paroxysmal or intermitting. In gastritis, the patient lies on his back, without moving, with his knees drawn up—in cramp, he sits up, wiih his body bent forward, or writhes about during the violence of the pain. In gas- tritis, the skin is hot and dry—in cramp, it is generally cool and moist. Hiccough is a com- mon symptom in gastritis—in spasm it seldom occurs. Autopsic phenomena. The inner coat of the stomach thickened and red, with gangrenous, eroded, or ulcerated spots. Causes. Mechanical irritants; poisons; cold wa- ter, swallowed while the body is in a stale of free perspiration; over distension with food or drink; the sudden application of cold to the sur- face; suppression of habital discharges, &c. Treatment. Bleeding; the smallness of the pulse, and prostration in the beginning of the disease, no objection, but on the contrary a strong indication of the necessity of prompt and copious depletion. The pulse becoming fuller and less frequent, is an evidence that the disease is yielding. Blisters over the epigastrium, are next in impor- tance to bleeding; they are to be preferred to leeching, and should be early applied. Costive- ness must be obviated by enemata. Cathartics, CHRONIC GASTRITIS. 81 and the usual internal antiphlogistics wholly in- admissible. Copious draughts of bland, muci- laginous drinks, beneficial Opium, a valuable remedy in this disease: after the violence of the local and general inflamma- tory excitement has been moderated by depletory measures, I know of no remedy that is so useful in allaying the vomiting and gastric pain, and producing a general and salutary diaphoresis, as opium in large doses. I have given two grains of this narcotic, in some exceedingly vio- lent cases, with the happiest effect. CHRONIC GASTRITIS. Chronic inflammation of the mucous membrane of the stomach, is of much more frequent occur- rence than is generally supposed. The worst forms of dyspepsia, and all that host of invete- rate gastric and bilious derangements, of which so much is heard, and the true nature of which is so often misunderstood, are, in nine cases out often, the consequence of a more or less phlogosed con- dition of the mucous membrane of the stomach. We are indebted to the French pathologists, and more especially to Broussais, for much new and valuable information, in relation to this variety of phlegmasial disease. (Pract. of Med. p. 191.) Symptoms. A pricking, lancinating, or burning pain in the epigastric or hypochondriac region; the pain is constant and harassing, generally con- fined to a very circumscribed spot, and often at- tended with a feeling of constriction; sometimes a sensation is felt, as if a ball were pressing on the diaphragm; at others, as if a bar were fi