iSg CV'^^V.'Cl ___..fc»_____ /r in s i _ipQs\ 3NIDK33W JO AUVaflll IVNOUVN v»8n IVNOUVN IY OF MEDICINE ^Kn/ NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE i jC\i/5 ^ ivaan ivnouvn 3nidio3vy jo Aavaaii ivnouvn ' V! W>! x If AE A - 3noio3w jo Aavaan ivnouvn NATIONAL LI "o —V <* m 3NI3K13W J RY OF MEDICINE *3v NATIONAL LIBRARY OF MEDICINE 3NOia3w jo Aavaan ivnouvn 1V88M IVNOUVN RY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE »V»fln IVNOUVN \ 3NOI03W jo Asvaan ivnouvn M : X '^^ - v^r- RY OF MEDICINE 3NIDI03W JO AoVaflll IVNOUVN *i^i^!^!# NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE V^ ^Y S. . ,7r H 3NIDIC13W JO AaV88n IVNOUVN NATIONAL LI Y OF MEDICINE MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDIC NATIONAL LIBRARY OF MEDICINE vn 3NIDI03VY jo Aiivaan ivnouvn VN . 3NIDI03W JO AMVJiail IVNOUVN VN 3NIDI03W JO AMVJiail IVNOUVN CINE ^ ?; NATIONAL LIBRARY OF MEDICINE >£f > Dr. Wilson Philip performed experiments prior to Dr. Thomson, on the frog's foot; and having first proved that he could create in- creased action in the capillaries without exciting inflammation, hap- pened to meet with one unfortunate frog, who had already by some means contracted inflammation; and he found upon applying the microscope, the vessels greatly dilated, and the motion of the blood extremely languid;—and he says, " It was at once evident, on observ- ing the part through the microscope, that where the inflammation was greatest the vessels were most distended, and the motion of the blood was slowest." Dr. Wilson Philip wetted the web of the frog's foot with distilled spirits; but although he continued to keep it moist for ten minutes, or a quarter of an hour, he could not perceive the slightest symptoms of inflammation. " The vessels, instead of appearing redder and more turgid, were evidently/?a/er and smaller than before the application of the spirits." No wonder. Distilled spirits is the most deceitful applica- tion he could have used for such an experiment. In the first place, it might stimulate the circulation in the part, but its quick evaporation would necessarily produce coldness, which, no doubt, caused contrac- tion of the vessels, and rendered them paler and smaller. Dr. Hastings has subsequently repeated these experiments corrobor- ating those of the last named author. In all the experiments, whether performed by Thomson, Wilson Philip, or Hastings, the velocity of the blood is represented to have been increased in the capillaries, in the state of simple excitement; but it constantly happened, when inflam- mation commenced, that no globules could be seen in the blood of the affected vessels. Now, whether are we to join Dr. Thomson in con- cluding that they cannot be seen because of the •' rapidity of their motioyi" or Dr. Hastings and others, who state that the blood in an inflamed part becomes itself morbidly changed, so that no globules can be detected? The point in dispute is thus brought within a very small space, and the reader is left to form his own opinions. The result of my investigations on the subject shall now be detailed; and it may be stated, that this has not been done hurriedly, but after con- siderable experience, and a very careful review of all that has been written on inflammation. It appears to me, that the view taken by Mr. Syme, in an Essay on Inflammation,* is the most philosophical. He thinks that too much attention has been directed to the obvious signs of inflammation, » Published in the Edinburgh Medical and Surgical Journal, vol. 30, p. 316. 14 INFLAMMATION. viz. redness, heat, swelling, and pain, and too little bestowed on the altered functions of the part. Mr. Syme justly thinks, that" if this remarkable character of inflammation had been kept in mind, patholo- gists would hardly have spent so much labour in disputing about con- traction and dilatation of the vessels, since it is obvious, that mere difference of capacity, though it might, to a certain extent, account for the redness and swelling, could never enable us to explain the altera- tion of function, any more than a knowledge of the size of capillary vessels could instruct us as to the mode in which their secretions, &c. are performed during health." And he maintains, that " redness and swelling ought to be secondary considerations in the investigation of the inflammatory state, in comparison with the grand distinguishing character of altered function.'''' Three points seem to have been much overlooked by writers on inflammation. 1st. The influence of the nervous system; 2dly. The changes in the qualities of the blood itself; and, 3dly. The disorder- ed functions of the capillaries. I have performed experiments upon horses, which prove most satisfactorily the influence which the nerves have, even in chronic inflammation. It is well known that these ani- mals are very liable to inflammation in the foot, from different causes; and I have seen horses who had been lame for months, cured by di- viding the nerves immediately above the fetlock joint, the effect being sometimes instantaneous, and occasionally permanent. With regard to the second point, there can be no doubt that the blood in the part af- fected becomes diseased; the red particles cease to be observed, and the blood assumes a flocculent appearance, becoming darker and darker, and the vessels become in some degree obstructed. It is not improbable that this change on the blood may be found to depend partly, if not princi- pally, upon the cessation of nutrition and exhalation, and at the same time a stop being put to the conversion of arterial into venous blood. It has been long known, that increased action of the vessels does not constitute inflammation, as we see every day illustrated in the act of blushing, and by the employment of friction to any part on the surface of the body. In these instances, the vascularity soon subsides on the removal of the causes. But we can produce actual inflamma- tion by a continuance of the friction; the blood will accumulate and we shall have all the phenomena, and the usual effects of slight super- ficial inflammations. It may be produced also by obstructing the flow of blood in the limb for a sufficient length of time, by applying a ligature; and this is what actually happens in a case of strangulated hernia. INFLAMMATION. 15 Diminished action of the vessels may be produced and maintained for some considerable time, and the effect will perhaps be, not inflam- mation of the part itself, but of another part of the body at a distance. Again, if inflammation has been excited in an organ, an increased flow of blood takes place towards it, and all other parts must consequently suffer from a diminished supply of arterial blood; this increases the embarrassment in all organs, hence the general constitutional disturb- ance. In the practice of physic, this last circumstance is too frequent- ly overlooked. Physicians are apt to expect a cessation of the con- stitutional symptoms the moment the original disease is subdued; this not being the case, they often push their remedies far beyond the proper point, and make matters worse. This is perhaps more pecu- liarly a British error, and we are justly condemned for it by our con- tinental brethren. Other physicians, again, do very great mischief by stimulating and throwing in bark and other tonics too soon after convalescence has commenced,—they will be found in the morning ordering a large bleeding, and in the evening a stimulant. Cases no doubt occur in which a more immediate change may be necessary; all that is wished to be impressed upon the reader in this part of the work, is, that such practice is too often had recourse to, more from an unfounded dread of the occurrence of " typhoid symptoms," than from real necessity; and that sufficient confidence is not placed in the powers of the constitution to repair injuries which have been sustained. Physicians are too often found tampering with the human frame, as if it resembled a piece of machinery of their own construction. The essence of inflammation, partly consists in more blood entering by the arteries than can escape by the veins, or than can be made use of when the part is in a state of health, when its functions are ac- tively performed; the consequence is an accumulation of blood, or congestion and effusion from partial obstruction; and it is, I imagine, this degree of obstruction which produces the throbbing. The ves- sels of the inflamed part are greatly dilated, and the number which contains red blood is greatly increased. It must be confessed, that in inflammation there is much undisco- vered. Physiologists have to settle several disputed points in the doctrines of the circulation; and anatomists have to discover a great deal regarding the anatomy and physiology of the nervous system, before pathologists can be expected to advance their part of the science of medicine in any remarkable degree. Considerable difference of opinion still exists among physologists whether the circulation of the blood in the capillaries depends entirely 16 INFLAMMATION. upon the vis a tergo it receives from the heart, or whether these vessels have an impulsive power independently of the heart's action. Those who examine this subject without preconceived notions, and with no other view than to discover truth, cannot reject the vis a tergo which the whole column of blood is regularly receiving from the heart. Neither can they reject the action which the vessels pos- sess from their elasticity, in aiding other parts of the machinery, not to mention their power of contracting themselves even into much smaller diameter than is natural to them, when circumstances require it for the preservation of life. With respect to the first point, it will be observed, that if one of the smallest arteries of the body, and at the greatest possible distance from the heart, be divided, the blood will be perceived to flow per saltum. As to the second, if the extreme vessels are quiescent, not possessing any power of acting within them- selves, and depending entirely upon the action of the heart, how could irregular determinations of blood take place? When any internal organ is inflamed, we are taught, by experience and observation, to apply blisters and other irritants to the surface of the body, as a part of the remedial process. These applications excite a temporary in- flammation on the surface, sometimes to the complete relief of the in- ternal diseases This translation, as it may be called, is not affected through the agency of the heart, by contractions of which the blood is propelled into the vessels generally; it can, in all probability, have no power to send blood to one part, in preference to another. The result of Mr. Syme's experiments lead me to suspect that some notable errors or oversights have been committed by Hunter and other experimenters upon the circulation. In the essay above alluded to Mr. Syme, in endeavouring to refute the received notions respecting the circulation in the capillaries, makes the foliowin°- statements:__ « In this case, also, we ought to discover, through the microscope, not only a change in the capacity of the capillaries, but an oscillatory movement of the globules passing through them. Instead of this, we see the capillaries apparently quite rigid and immoveable, while the globules shoot through them in such a free, unconstrained manner, as to convince every observer that they are not impelled by a vis a tergo." The results of one of Mr. Syme's experiments are worthy of being quoted in his own words.—"I have repeatedly seen the ^lo- bules continue in motion through the capillaries of a frog forty ntin utes after the whole heart was excised. And this motion was not uni- form,-either as to direction or velocity, in which case the gradual contraction of the vessels might have been supposed adequate to ac INFLAMMATION. 17 count for it,—but sometimes this way, sometimes that,—at one time quick, at another slow,—and always continuing quickest as well as longest in the smallest vessels. While in health the motion of the blood is slowest in the capillaries." Having been an eye-witness to these experiments, I can add my testimony as to their correctness, and that every precaution was taken by Mr. Syme to guard against the possibility of any fallacy. Before concluding this subject, I beg to enter my protest against the employment of the term "debility," as too generally applied to the capillary vessels of an inflamed part. If a man were able to walk three miles in an hour with an ordinary burden on his shoulders, it surely would not be correct to say he is in a state of debility because he could not go over as much ground if he had to carry an additional hundred weight. This is exactly the condition of the blood-vessels; they are well able to perform their natural functions, but when over- loaded, they are rendered incapable. Causes of Inflammation. In stating the causes of inflammation, it is my intention to avoid adverting to occult causes. In medical investigations, it is very in- jurious to the science to affect being over-wise, and it is surely more philosophical to confess our ignorance, than to attempt, by special pleading, to leap over difficulties, which,inthe presentstate of our know- ledge, are insurmountable. Instead of descanting at great length upon proximate, remote, exciting, and predisposing causes, it will be better to speak of common and specific causes of inflammation. The disease itself is improperly termed by Cullen and others, the "proximate cause;" this term will, for a considerable time to come, be fostered by symptomatica! physicians, who call the symptoms the disease, and the disease the proximate cause; but there is no reason why it should be retained in this work, unless it were employed to denote the proxi- mate cause of the symptoms. As to predisposing causes, it is more consistent to take them into consideration when treating of prevention of diseases; but many writers have been guilty of great absurdities even with regard to their influence in the production of disease. One author with whose writings most medical men are well acquainted, in treating of the predisposing causes of hooping-cough, mentions, among others, " a serous temperament,—a scrofulous constitution,— dentition,—a disposition to contract catarrhal affections,—the retro- cession of eruptive diseases.,, Vol. 1.—;< 18 INFLAMMATION. The common causes in the production of internal inflammation are, exposure to cold; sudden vicissitudes of weather, particularly when the air is damp; irregularity of bowels; unwholesome diet; insufficient clothing; cold drinks, particularly when the body is warm; depress- ing passions, &c. Almost all these causes tend to produce inflamma- tion in the same manner, by inducing irregular distributions of the blood, and venous congestion. The lost balance of the circulation is marked sufficiently well in the beginning of almost all acute diseases, by the accession of rigors, coldness, and paleness of the surface of the body. Some individuals are more liable to inflammatory attacks than others, and some to inflammation of a particular tissue or organ. Such persons may well be said to be liable to, or susceptible of, such disease; there can therefore be no objection to the term in this limited sense. Few persons escape inflammatory affections produced by specific causes. The contagion of small-pox is termed a specific cause, because nothing is capable of producing the disease but its own contagion, in whatever way it is communicated. Measles is produced by a specific cause. Scarlatina also, and perhaps hooping-cough. Erysipelas is not to be ranked with these specific diseases, because it is not produ- ced by a specific cause, as is too generally imagined. If erysipelas were produced twenty times, by inserting matter taken from an erysipelatous surface, expressly for the sake of experiment, still it can- not be ranked as a specific disease, because it has also followed an in- jury produced by a splinter of wood, a perfectly clean sewing needle, a rusty nail, &c. It has also occurred after a prick received in dissec- tion. No one ever alleged that small-pox, measles, or scarlatina, were ever produced in this fortuitous manner. It may be also mentioned that there are other matters, the nature of which is unknown, but the effects of which are capable of producing inflammatory affections, viz., malaria, sometimes denominated marsh miasm, and human effluvia, to- gether with another and still more mysterious agent, epidemic influ- ence. But it appears to me, the great agent in the production of in- flammatory affections is the sudden application of cold to the surface of the body, particularly when the stomach and bowels are out of order, and the mind depressed. Cold wet feet, for example, will sometimes produce determination to the head, and phrenitis will be the consequence; or to the lungs, producing pneumonic inflammation, &c. Dr. Thomson states that this cannot be explained upon any prin- ciple. The doctrine of determination of blood explains it so far, and in my humble opinion quite far enough for all practical purposes. It INFLAMMATION. 19 is not, however, actual, but relative cold, which is so prejudicial to the human body; it is exposure to cold, when the body has been previ- ously much heated. An individual, after sudden exposure to a cold damp atmosphere, may be attacked by inflammation of the lining membrane of the air passages. It becomes an interesting and important question to de- termine upon what part of the human frame the cold air acts. Dr. Thomson says, at page 57 of his work on inflammation: " In some instances, cold, or a diminution of temperature, seems to act more di- rectly upon the parts with which it comes in contact. We have proof of this in the inflammation of the mucous membrane of the nose, fauces, trachea, and bronchia?, from the inhalation of cold air." This is a most unhappy illustration. It is apparently a matter of little consequence how cold the air is which passes into the lungs, provided the body be sufficiently protected by warm clothing. In cold regions, if Dr. Thomson's hypothesis were true, an individual ought never to be free from bronchitis. We are assured, however, that the sailors in the voyages of discovery, which were made by Captain Parry, to the North Pole, enjoyed remarkably good health. There is another curious point which must be noticed. Extreme cold produces exactly the same sensations and the same effects upon the living animal fibre as intense heat. Take a piece of frozen mer- cury in the hand, and it will cause a sensation similar to that produced by hot iron,—inflammation and vesication follow; and if applied long enough, destruction of the part will take place. The hot iron destroys vitality by the addition of too much caloric; the frozen metal by ab- stracting it too suddenly. Division of Inflammation into Varieties. Inflammation has been variously divided and subdivided. The terms acute, sub-acute, and chronic, will be employed in the course of this work, as being sufficiently precise, and well understood. It is wished to avoid the use of the term -' passive," because it is employed too vaguely, sometimes to express the existence of sub-acute inflam- mation, at others that of the chronic kind. John Hunter also institu- ted the terms healthy and unhealthy. Is inflammation a disease? If it be, it is certainly not proper to call it healthy. Other varieties of inflammation have been mentioned, as scrofulous, gouty, rheumatic, cry thematic, erysipelatous, &c; but it is my belief, that as pathology improves, these terms will be less frequently employed. Another '20 INFLAMMATION. obvious division of inflammation depends upon the tissue or organ affected. Phenomena of Inflammation. External inflammation is characterized by redness, swelling, heat, and pain. All these taken together, leave no doubt as to the existence of inflammation. In this respect, surgeons have the advantage of phy- sicians. They can see and feel the part affected, in addition to the power of judging from the constitutional symptoms, and the account the patient gives of his own sensations. Whereas, in physic, we have greater difficulties to encounter in forming a diagnosis. We observe local and constitutional symptoms also; but it does not always follow, because there are dyspnoea and fever, that the lungs are inflamed; the disease may be inflammation of the pericardium. There may be vio- lent vomiting, tenderness in the epigastrium, thirst, with more or less fever, while the disease is in the head. There may be severe local and constitutional disturbance, without the existence of the slightest degree of inflammation, merely from a neuralgic affection of some tis- sue or organ, or from impeded function of some viscus. During life we cannot see the state of internal organs to ascertain whether they are red and swollen; and a sensation of heat, pain, and fever, may exist without the least inflammatory action. It will be proved, in a subsequent part of this work, that the pulse cannot be depended on. With respect to buffy blood,* it may exist without actual inflammation; and, in inflammatory complaints, the blood does not always yield it The shape of the dish modifies this appearance, so does the manner in which the blood flows from the vein. Mental agitation and fatigue produce the buffy coat. Sometimes it does not appear on the blood till the patient has been largely and repeatedly bled. I am inclined to place considerable dependence, however, on the buffy coat, taken in connection with other circumstances, particularly when the sur- face is also concave, or " cupped," as it has been termed, and when the quantity of serum is proportionably large. * Blood is said to be « buffy," when the surface, instead of being of a reddish color, presents a yellowish crust of greater or less thickness. There are various opinions as to the cause of this appearance. Some attribute it to the slower coaes, and are attributable to the sudden attack of some very important iuternal organ necessary to life. The termination of irritation is more or less rapid according to the tissue in which located, the cause producing it, or the character of the sympathies which it has brought into energy. The state of irritation under which an organ or tissue labours, pro- ductive of increased vital movements, is called hyperemia. It will be necessary to devote a few words to sub-irritation or an- xmia. In this case, life in an organ is below the normal standard, the organic movements are depressed, and weakness and debility of its functions are the consequence. It is the very opposite of irritation; hence a short account of its causes and laws will be sufficient for our purpose. An ancemic condition of an organ is rarely primitive, it is rather the result of irritation located in some other vi>eus. The following explanation will convey a correct idea of what is understood to be its nature. Those organs which are not themselves irritated, and do not receive transmitted irritation; are in a state of prostration; be- 44 [physiological doctrines.] cause organic activity is concentrated in others, and withdrawn from them. If this were not the case, the first law of irritation would be in- correct, for then there might be a repetition of it in all the organs, and universal excitement be present, which is an impossibility. For example, when the heart and vascular system are stimulated to increased activity by the existence of visceral irritations, muscular power diminishes; when the locomotive apparatus is violently excited or convulsed, nutrition languishes, the secretions are impaired, the heart circulates blood irregularly, the brain is weakened in its intel- lectual operations. In maniacs, where the brain is in a state of high activity, the heart and muscular system may have acquired more energy, but the secretions are interrupted, the intestines rendered dry and insusceptible to stimulation, nutrition is suspended in them, and the sero-cellular tissues are in a state very opposite to that of in- flammation. By this view of things the idea of diathesis, as meaning general habit, is refuted. Anaemia may be produced in three ways: 1st, By the abstraction of all stimulation from an organ: 2d, By diminishing the stimulating in- fluence which one organ receives from another by sympathy: 3d, By the intense excitement of some important organ concentrating activity in itself. An anaemic state is marked by the following appearances and symptoms—Paleness, flaccidity, coldness and insensibility, diminution or total depravation of functions. Sur-excitation and intense local mobid congestion are compatible with the general diminution of the forces. This is one of the most important truths of the physiological doctrine, and ignorance of it has led to doubt, uncertainty, and erroneous practice. Diseases essentially active, in consequence of mistaken ideas of their nature, have been treated for those of opposite character. It is difficult to convince persons that when exhaustion and marasmus are the predominant symptoms, a focus of irritation is present, and progressing with its ravages; the gene- ral condition is confounded with the local, because just and correct ideas have not been entertained of the latter; in other words anaemia of a majority of the organs is taken as the standard of the whole. To conclude these remarks, we may state, that it is impossible to understand the derangement of the molecular action in the tissues of an organ; the most that can be accomplished is to investigate the sen- sible alteration of structure which they have undergone. To know the seat of a disease, is to know in which organ and tissue it is located- to understand its nature is to recognise in what consists the organic [physiological doctrines.] 45 alteration which constitutes it. Pathological anatomy is employed in this research. The errors in pathology, says M. Boisseau, have arisen from the following causes; 1st, Symptoms have for too long a time been the sole objects of study; 2d, It has been supposed that they always faithfully represented the condition of viscera removed beyond the scrutiny of the senses; 3d, It has been neglected to look to the or- gans upon which each one of the morbific or therapeutic agents first exerted its influence, and the laws which preside over the propaga- tion of this influence from one to another; 4th, It has been supposed that these agents must act upon the whole system at once, as they are recognised to influence a simple organ; 5th, And finally, it has been inferred, that as the whole organism is concerned, all the organs were primarily affected. Having thus explained the laws of irritation as announced by Broussais, we shall now proceed to consider his theory of fever founded upon them. According to this hypothesis, all fevers owe their origin to a local irritation or inflammation, by the reaction of which upon the other organs, through the medium of the sympathies, that group of phenomena is produced which is called febrile disturbance. All that class of fevers commonly termed idiopathic, together with certain forms of traumatic fever are attributed to an inflammatory condition of the mucous membrane of the stomach and bowels, and are therefore denominated " Gastro ententes." No matter what form the fever may assume, or by what name it may be designated, whether ataxic, adynamic &c. it is still referred to this primary lesion. Es- sential or idiopathic fevers are therefore regarded as chimerical, not founded in nature or sustained by observation. In support of this doctrine he appeals to the history, symptoms, and postmortem investi- gation of the disease. We shall see hereafter how far this theory is sustained by the researches of those who, in the same locality, and enjoying the same advantages, have entered upon a similar field of observation. To establish the truth of the assertion, that the seat of fever is primarily local, he has recourse to numerous arguments, which will be detailed in succession. " Inflammatory fever represents an excitement of the vascular san- guine system, which is the consequence of all local irritations; this is admitted by all nosological writers. A local excitement will always be found predominating, and nothing proves to us that it is not the immediate cause of that form of febrile movement which has been hitherto considered essential." "Modern writers, in considering in- flammatory fevers as idiopathic (essential,) have not pretended that 46 [physiological doctrines.] that they were independent of local irritations, since they tell us that a debauch, a violent fit of anger, excessive pain of a wound, &c. every physical or moral cause sufficient to establish a permanent reaction of the vascular sanguine system, can produce fever."—"We are of the same opinion with them, that all the inflammations can produce fever, but are not prepared to admit that fever, which is acknowledged to arise from all local irritations, can ever exist of itself, which it must do if it be essential." What is meant by the terms, mucous fever, bilious fever, &c. if they do not depend upon corresponding irritations? Ac- cording to those who use these expressions, the irritations which pro- duced such fevers are not inflammations, and yet they are sufficiently se- vere to excite fever, and after death the organs are found in a state of inflammation. Reference to the laws of the animal economy, the nature of life as far as its modes can be ascertained, the character of irritation, its peculiar local phenomena, and manner of propagation by means of the sympathies, are brought to influence the weight and force of his rea- soning. But he further endeavours to establish that the primum mobile of febrile disease is in the stomach and bowels.—These,of all the viscera, seem particularly adapted to receive morbific impressions, not only from the central position which they occupy, but from being in rela- tion with the exterior world, and having the greatest number of sym- pathies radiating in all directions. By means of deleterious agents introduced from without, irritation is created on their mucous surfaces; inflammation succeeds, and then commences the congeries of diseased associations, which at all times have been regarded as fever. The first morbific impression then, is made upon the stomach; and it may be brought about in two ways. The first, which is direct, has been indi- cated above; the second is indirect, and .irises from sedative impressions upon the skin, or transmitted irritation from a remote part It is a fact, that inflammation of the stomach, is always attended by a simi lar condition of the small intestines, and in the following manner. It is always upon the stomach and duodenum, that the first impression is made; from these the remainder of the small intestines are im- plicated by direct propagation. Irritation in the organ being thus established, its characteristic functions will be impaired, an inor- dinate determination of blood will take place towards it; turgi- dity of the tissues, heat, &c. are the consequence; fulness of the ves- sels and corresponding oppression and weight in the abdomen follow, and the irritation, extending to the liver and small intestines will announce, by appropriate symptoms, the commencement of the malady. Under these circumstances we are presented with loss of [physiological doctrines.] 47 appetite, nausea sometimes vomiting, thirst, uneasiness and pain, abdominal heat, throbbing and increased sensibility to pressure. But an acute inflammation once begun in so important an organ cannot long remain isolated; its effects are disseminated to others. Irradia- tion of irritation is the Ariadnean thread of the physiological doctrine; it is the clue to the proper understanding of fever. The brain and ner- vous system are invariably made to sympathize, as the next link in the chain of diseased associations, proclaimed by uneasiness, confu- sion of ideas, weight, and headache, disinclination to motion, intoler- ance of light, and diminution of intellectual vigour: there may be pain in the back, loss of muscular power, and a general state of uneasiness, which informs us that the spinal marrow is likewise involved; the cerebral disturbance becoming more intense, depression of spirits, aug- mented pain, wandering of thought, and delirium indicate a true cepha- litis. As all irritations of organs are first made sensible in the brain and spinal marrow, as the common centre of nervous action, from these it is reflected anew into distant parts of the system, and the next in order is the heart. The contractions of the heart are augmented in force and frequency; blood is more rapidly driven into the arterial system of vessels; the pulse is quicker and fuller; the capillaries of the skin are injected, heat and redness are increased, the secretions are im- peded, and dryness results. In this way the feverish condition is com- pletely established. The accession of a paroxysm of fever is usually attended with chilliness—it is in consequence of the first effect of irri- tation in the internal viscera withdrawing blood from the surface and accumulating it in their vessels, causing the overwhelming sen- sations of internal congestion which are experienced. The heart oppressed and at this time not sufficiently influenced by the force of sympathy to stimulate it to increase exertion, is feeble in its movements; but when aroused to vigorous effort, throws off the load of blood accumulated around it, and brings about a state of reaction, as- sisted, in a measure, by a sympathetic irritation established in the skin. As the disease advances, the number of sympathetic morbid disturbances is multiplied; the tongue becomes dry, red at the edges, pointed, coated, and trembling; the lungs liver and kidneys are more or less affected. This outline deduced from the introductory account of irritation, whereby the production of fever is explained, evinces how impossible it would be to convey just ideas, were not the play of sympathies rightly understood. We must now enter into an explanation of the manner in which these laws can be applied to all the forms of fever. From the symp- 48 [physiological doctrines.] toms which have been detailed, it will at once be perceived that they belong to both systems of organs—those of relation, and those for the maintainance of the individual. Now all the irregularities presented by fever are referrible to one of these two systems, and determined by the preponderance of irritation in some particular organ. Thus, in some instances cerebral disturbances are the most marked, because the in- tensity of irritation in the brain is greater than elsewhere; pulmonic symptoms greater than ordinary may appear and characterize the dis- ease, but without altering in the least the priority of irritation in the stomach; these forms are termed ataxic. Prior to the development of the physiological view of fever, the names which were employed to express the predominance of certain groups of symptoms conveyed no definite idea of their cause, nor did they inform us of the condition of the organs which gave rise to them. In accordance with the ex- pose which has been exhibited, bilious fever is nothing more than an extension of irritation to the liver, exciting or depressing its functions, and producing the phenomena enumerated in nosological treatises as constituting that disease; so of mucous fever and others. The same disease at different periods may assume different phases—inflammatory in the beginning, adynamic at the termination, but without changing its identity. The symptoms of adynamic fever are stupor, a fuligi- nous appearance of the openings of the mucous membranes, small feeble pulse, cold clammy skin, and fetor; these are the most promi- nent. The rationale, according to the principles laid down under the head of anaemia is evident A concentration of vital action takes place in the internal organs at the expense of the external surfaces, the func- tion of assimilation and chylification is totally impaired; a small amount of blood is elaborated and conveyed into the general circulation; imper- fect haematosis consequently follows, and the suspension of nervous energy and pulmonary oxygenation adds to the universal complication; hence the symptoms enumerated. From the foregoing reasoning and mode of explaining the phe- nomena of fever, the following conclusions are to be drawn: 1st. All fevers supposed essential, are of local origin. 2d. They originate in the stomach and intestines. 3d. The affection of these viscera is inflammation; hence it is called gastro-enteritis. 4th. This primitive inflammation is communicated to the brain, pro- ducing cephalitis, and finally reacts upon most of the organs, exciting their movements, and constituting fever. These are the ideas of Broussais himself upon this complicated and [physiological doctrines.] 49 important subject, and to a great extent have been adoptedby his pupils. Some difference of opinion, however, exists among his contemporaries, and the reasons for their dissent are contained in the various treatises which have been issued within a few years. Boisseau in his Pyreto- logiePhysiologique fully coincides in the first conclusion; because no morbific cause acts at the same time upon all the organs, because the symptoms never are refcrrible to the whole of them, nor are they equally intense in those affected; because in all diseases irritation commences ' in some one organ, and extends to others; and lastly because no dis- ease, however general, leaves after death characteristic traces of lesion in every organ of the body. But to the second conclusion of Broussais he enters his protest, supported by the following facts. 1. The causes of fevers do not act solely upon the gastro-intestinal mucous mem- brane. 2. Although this membrane may be influenced directly or indirectly, yet this is not always the case, and if it is, the effect is very often of the lightest character. 3d. Irritations of other organs, can act upon the heart, brain, lungs, &c. and produce fever. 4. An at- tentive study of the causes, and a close examination of the symptoms evince that the gastro-intestinal mucous membrane is untouched, or so slightly disordered as not to sanction the conjecture that at this point the disease originated. 5. After death not only no trace of lesion is found in this membrane, but on the contrary the highest degree of an- atomical change is observed in other parts of the body. We do not wish it to be understood that gastro-enteritis is excluded entirely by this author, but that he merely admits the stomach, as one of the or- gans primatively alfected, it is one of many which can lead to the same results. It should be stated, that these remarks are intended to apply to all fevers termed essential, and M. Boisseau is as full a believer in the localization of disease as Broussais. When typhus fever, &c. are no- ticed it will be seen how far he is correct. " The two opinions, the one that fever is a disease, sui generis, pervading the whole system, the other that it is a gastro-enteritis, are equally remote from the truth; nevertheless they both have been extensively adopted, in as much as they are well calculated to please superficial or enthusiastic minds." Inflammatory fever is a generic term, applicable to all fevers, and including the whole range. When the symptoms, as the disease is developed, announce derangement of some organ in particular, be- stowing a marked character, the- specific name is derived from this organ: hence we have gastro-enteritis, cerebritis, &.c. Another source of specific nomenclature, is the presence of some positive or imagi- V ol. I.—7 50 [physiological doctrines.] nary concomitant circumstance; as for instance, if there be prostration, it is called an adynamic fever; if irregular in symptoms, ataxic; should there exist fetor or disordered and vitiated secretive action, it is call- ed typhus, yellow, or pestilential fever. One cause of the difficulty in coming to correct conclusions with regard to the nature of fever, is the employment of terms vague and unmeaning to express the different forms under which it appears, and the same form is so frequently described under different appellations, that it is impossible to attach precise ideas to them, or to understand what is their signification. It seems to be a difficult task to locate satisfactorily in any one organ, the causation of fever; hence the dis- cordant opinions entertained as to its primary seat, or in other words, its specific nature. The brain is contended, by some writers, to be the first affected; the heart, the skin, the lungs, by others; while, as has been exhibited, Broussais is unqualified in his gastric pathology. But where there is no manifestation of an undeviating specific location, exhibited by the symptoms, it is difficult to be persuaded that an acute disease arises from a serious disorder of an organ, (and serious it must be if it can produce such intense disturbances,) yet no evidence be pre- sent to prove that this organ is implicated. The only conclusion which can be obtained from these statements is, that there are as many pri- mary locations of fever as there are organs, and consequently we are not to look invariably to one for an explanation of the phenomena. If exclusiveness of location is rejected, the first symptoms are to be expected in the organ where disordered action has commenced; and whether they continue to be the most prominent, or in the progress of the disease are obscured by those which are sympathetic, their pri- ority will lead to a knowledge of the first link in the chain of disease. A sketch of the task assigned to the physician by a right com- prehension of physiological medicine, will now conclude the general remarks which have been made. And that it may be rendered more obvious to the reader, the form of axioms will be adopted. 1. Nothing should be neglected to ascertain what tissue in the indi- vidual who is the subject of disease, possesses a preponderance, and modifies his constitutional tendencies, or to understand to what morbific agents he has been exposed, and upon what organ they first made their impression. 2. To trace by means of all the information to be obtained, the propagation of morbific actions from organ to organ. 3. To refer each symptom to its appropriate organ. 4. To avoid being deceived by the appearance of some symptoms more prominent than others. To distinguish those which proceed [physiological doctrines.] 51 directly from the organ first diseased, or more intensely affected, from those which occur secondarily, or are light in character. 5. Finally, From the investigation of the morbific causes, the in- dividual predisposition, and the principal location of the symptoms, to deduce the nature and seat of the disease. The nature and seat of the disease being ascertained as far as prac- ticable, we must make choice of such therapeutic agents as will di- minish its intensity. Since disease in organs is either a state of irritation or anaemia, al- ways primitively local, it will be necessary to calm and soothe the first, to excite and stimulate the latter. It is only possible to regulate or- ganic actions. It is out of our power to bestow force and energy when the excitability is below a certain standard; and when irritation exceeds the amount compatible with the organic soundness of a tissue, terminating in disorganization, our means are equally fruitless. The first rule in therapeutics is to get rid of all morbific agents still producing an effect upon the organ, after which, irritation can be com- batted by different means, all efficacious when applied properly, but not to be used indiscriminately. To weaken the organic action of an irritated part it is necessary to diminish as much as possible the number and energy of the stimulants which act habitually upon it; after which we may reduce the quantity of nutritive matter deter- mined to it, and changing its relative bulk. In this manner diet and blood-letting produce their beneficial effects, while refrigerating and emollient applications soothe the sur-excitation and guard the surface from external influences. If an irritated organ is so situated that the capillaries of the part itself cannot be emptied, we must operate upon them through the near- est organ, or the one most intimately connected with it sympatheti- cally; hence in gastric fever, the application of leeches immediately over the stomach will be most efficacious, but where the heart and blood vessel system assume marked exaltation of energy, the reduction of this by general abstraction of blood will be most proper. To these means which are called a?itiphlogistic, are conjoined, others termed derivative, which will be found all important in their proper place and time. They consist of irritants applied to remote organs or those unin- fluenced by disease; such are rubefacients, blisters and caustics; emetics, purgatives, diffusible stimuli, stimulants of fixed character and tonics. There exist cases where the direct application of stimuli to an ir- ritated part, removes the irritation; these are called purturbative ap- 52 [physiological doctrines.] plications, and are more or less dangerous, either in their immediate or remote consequences, and call for the greatest caution in their use. When irritation is intense, the only safe plan of treatment is the anti- phlogistic. After this has been carried into operation, the derivative comes in, with peculiar efficacy. Should, however, the employment of derivatives be too early or too closely applied to an irritated part, they may, on the contrary, be productive of an aggravation of the affection, particularly of its sympathies. Intermittent irritation is to be treated in the same manner as the continued kind, only in the interval such stimulating derivatives are to be given as to diffuse revulsive excitement through all the organs and prevent a recurrence of concentration upon one. The same rules are to be followed in the treatment of asthenic or the anaemic condition of organs, reversing their application in accord- ance with the opposite state of circumstances. Thus, all sedative in- fluences are to be removed, moderate stimulation substituted, and the nutritive actions of the part increased by proper food and exercise. The modes of changing the vital movements are the same as if irritation were present; the organ itself may be acted upon, or it may be done through the medium of others. Irritation and asthenia are so often combined, that it requires a nicety of discrimination to pursue op- posite courses in different organs, without undergoing the risk of ag- gravating either condition. It should also be remembered that excess of sedative measures to an irritated organ will induce an asthenic state of it; and that by stimulating too violently a weakened part, it may assume irritations. Sympathetic relations are also to be taken into account, in both of these therapeutic indications. Profound alteration of the texture of a part may follow, as an effect of the two states, irritation and anaemia. The management of such lesions must be conducted upon the same principles, by calming irri- tation and exciting the depressed vital forces, so as to produce a return of the normal texture, if the derangement has not proceeded too far; but unfortunately for the perfectibility of our science these are too often beyond the control of medicine.] It is now time that I should state the views which I have been led to form on this important subject. First. Fevers may depend on inflammation of an acute, but more frequently of a sub-acute nature, of some organ or tissue of the body. If the inflammation be acute, the febrile symptoms will be correspond- ingly high; but if sub-acute, they will assume a slighter form. FEVER. 53 Secondly. Fevers very often depend upon mere functional derange- ment of some organ, having as yet no connexion with inflammation. Thirdly. Fevers sometimes depend on the mere loss of balance in the circulation, producing local congestions; fevers arising from these last two causes are generally called idiopathic. [Although the term idiopathic fever is vague and unsatisfactory, yet in the present state of science it would be difficult to dispense with it. Every practitioner has- met with cases devoid of any predominant category of symptoms which point to a particular organ as being more materially disordered than others. In these cases it would puzzle the nicest scrutiny to locate the disease. The system seems literally to labour under a disorder which has spread itself universally through all its parts; hence, if the class be abolished, there would be no place for this form of disease in systematic treatises.] After having watched the progress and termination of fevers in va- rious climates, I have been led to conclude, that the nature and seat of : fever, (which may be called its essence,) is pretty much the same in all constitutions, in all climates, and under all circumstances; the leading difference being in intensity, and the rapidity with which some run through their course. Some have supposed, from the tenor of the papers which have been published by me, that I deny the influence of the nervous system in the production of fever; but this is far from being the case. It would as soon occur to me to question the laws of gravitation. I have always maintained the strict connexion between the vascular and nervous sys- tems, in producing and keeping up febrile and inflammatory diseases. There can scarcely be a doubt, that a disordered state of the func- tions of the brain, and other parts of the nervous system, occasionally gives rise to febrile action. It is impossible to deny to the brain, as an organ, that it may be disordered, like other viscera, in function, as well as diseased in structure. My ideas of fever may be summed up in the words of Dr. Fordyce, one of the best and most original writers upon the subject. "A fever," says he, "is a disease that affects the whole system; it affects the head, the trunk of the body, and the ex- tremities; it affects the circulation, the absorption, and the nervous system; it affects the skin, the muscular fibres, and the membranes; it affects the body, ami affects likewise the mind. It is, therefore, a disease of the whole system in every kind of sense. // does not, hoivevcr, affect the various parts of the system uniformly and equally; but, on the contrary, sometimes one part is much affected in proportion to the affection of another part."—Dissertation on Simple Fever, Part I. p. 27. 54 FEVER. It appears to me, that certain general views closely touching this question are admitted by all writers whose opinions are of any value, although the same facts have been called by different names, and have led observers to draw opposite conclusions. 1st. That the functions of almost all organs are embarrassed in fever from the very'beginning, and often for days before the sense of cold is felt by the affected person. 2dly. That the blood leaves the surface of the body, and accumu- lates in internal organs, and that, unless they are overwhelmed, the system makes an effort to relieve herself, and certain combined pheno- mena take place, which are designated by the terms " re-action, fever." A question has arisen to determine by what means this is effected. There can be no doubt that it is owing to the principles of life. There are two circumstances, in following which investigators have bewil- dered themselves; one is, the vain attempt to ascertain the first link in the chain of diseased action; the other is, the still more hopeless en- deavor to discover the principle of life, which perhaps no man will q ever be able to unravel. 3dly. That inflammation of all parts of the body will give rise to fever. 4thly. That inflammation may supervene during fever, without be- ing the primary cause of the febrile commotion. 5thly. That the nervous system is involved as well as the vascular; and, 6thly. It follows as a consequence, if all these things be true, that the blood itself must be in a diseased condition. This outline of my opinions must suffice at present,—it will be best filled up when treating of the pathology of individual fevers,—when an attempt will be made to account for the discrepant histories which have been given of fevers, and for the varieties of treatment recom- mended by different authors. Divisioyi of Fevers. Fevers have been divided into various kinds. Dr. Mason Good has four orders, thirteen genera, and each genus has several species. This is a very erroneous plan in writing as well as teaching; for every individual case has some peculiarity, so that this very learned author might with as much propriety have made many millions of species. It was the opinion of the celebrated Dr. Rush, that it is " not more improper to say that men are of different species, because some are tall, and others short, or because some are long, and others short-lived, FEVER. 55 than that fevers are of different species, because they vary in their symptoms and duration. Cullen has divided fevers into intermittent, remittent, and conti- nued; and this last is sub-divided into synocha, typhus, and synochus. It is my intention to reject the term " idiopathic,"* as applied to fevers, which I consider a most unhappy term, being one respecting which no medical man with whom 1 am acquainted can give a satis- factory definition; it seems to be a disease beyond the pale of patho- logy? having neither nature nor seat. It is defined by some to be a fever without a cause. Fever is alleged to be a certain combination of symptoms, but it cannot be said that this is the disease. The symp- toms are to be regarded as evidences*of a diseased condition of some part or parts of the system; whereas, those who speak of idiopathic fever, will be found very frequently to do so, either from habit, or from a dislike to change terms, they themselves having a particular meaning for it But the schoolmen who are in the habit of using this term, I verily believe, do so from an erroneous impression that the symptoms are the disease, and it is understood that some of them even go the absurd length of treating of idiopathic hectic! The terms adynamic and ataxic have been also avoided in this work, because there seems to be no good practical reason for their employ- ment. None of the arrangements which have been hitherto laid before the profession, exactly meet my views; and in so far as I have been able to observe the phenomena of fever, I believe they may be advanta- geously arranged under the following heads: 1st. Intermittent fever. 2d. Remittent or yellow fever; infantile remittent. 3d. Continued fever, sub-divided into four orders, viz. Fever from functional derangement. -----from inflammation. -----from congestion. A mixed form of fever between these three last, but in which congestion predominates, commonly denominated typhus or synochus. 4th. Hectic fever. 5th. Fevers attended with eruptions, subdivided as follows: Scarlet fever. Measles. •The fevers said to be "idiopathic" are "intermittent, continued, and exan- thematous." 56 FEVER. Small pox. ---------modified. Chicken pox. Miliary fever. Roseola. Urticaria. 6th. The Plague. General description of the phenomena of Fevers. The following are Cullen's definitions of febrile diseases, and of fever: First, of Pyrexia. " After shivering, succeed a quick pulse, increased heat, with inter- ruption and disorder of several functions, diminution of strength, par- ticularly of the joints." Secondly, of Fever. " After languor, lassitude, and other signs of debility, pyrexia, with- out any primary local affection." There are the strongest objections to all medical definitions. The following may be urged against the two above quoted; they are symp- tomatical definitions, and it is well known by physicians of experience, that the symptoms vary much according to constitution, climate, and habits of living. They vary even in different individuals belonging to the same family, and during the same epidemic. The symptoms develope themselves also in various degrees; one symptom, when ex- ceedingly severe, frequently conceals or disguises the others. A defi- nition, to be useful either to the student or the young practitioner, should embrace such phenomena as are peculiar to that particular dis- ease, and which never attend any other,—phenomena which may be therefore said to be pathognomonic of the affection. As has been already stated, there is no case of fever, or indeed of any other disease, which has not some peculiarity that distinguishes it from another; in truth, the symptoms of diseases have a very wide range of character. A definition, giving a sketch, not of the symptoms, but of the nature and seat of the disease, would be a most useful introduction to the practice of physic; but pathology, unfortunately, is not yet sufficiently advanced to enable me to adopt such a plan in the course of this work. It may be asked why Cullen, in his definition of fever, has taken no notice of pain in the head and in the loins, delirium, and coma, of oppression at the praecordia, of nausea, want of appetite, thirst, and the state of the tongue? The reason appears to me to be evident; the FEVER. 57 mention of these phepomena would have led to the suspicion of local affection, which was contrary to his own dogmas. "Fever," says Dr. Fordyce, "of all other diseases, is that one in which a pathognomonic symptom is least to be depended upon; that is to say, an appearance which does not take place when there is no fever, or a fever does not take place when there is no such appear- ance."* Febrile diseases sometimes commence without any rigor, and go through their whole course without any unusual heat of skin, quick- ness of pulse, or thirst. The rigor is not always followed by increased heal. Languor, lassitude, and other signs of debility, are symptoms common to almost all diseases, and therefore should not be ascribed to fevers in particular. It is impossible to give a good general account of the phenomena of fevers, because, in addition to the objections urged above, they vary every day in the course of the disease. The symptoms which appear in the accession of fever, differ from those which manifest themselves in its progress; and these again from those which are observed in the decline and termination. These differences have given rise to a divi- sion of every fever into stages: 1. That of accession. 2. -------increase. 3. -------declension. 4. -------collapse. These stages have been differently named; the first is sometimes called the stage of oppression and depression; the second, that of re-action; the symptoms occurring in the third and fourth stages have too fre- quently been called typhoid. The symptoms vary also according to the organs chiefly affected. In some cases there are decided cerebral symptoms, from the very be- ginning, indicated by headache, intolerance of light and sound, tinni- tus aurium, and delirium, or stupor with low muttering delirium, and sometimes coma. In other cases the viscera of the thorax are principally affected, indicated by dyspnoea, cough, expectoration, and tightness in the chest In a third set of cases, some of the viscera of the abdomen are implicated, announced by nausea or vomiting, un- easiness increased on pressure, obstinate constipation or diarrhoea, a morbid state of the alvine evacuations, discovered both by their ap- pearance and odour; a tympanitic state of the abdomen, and the pecu- » On Simple Fever, Part 1. p. 7. Vol. I.—8 58 FEVER. liar appearances of the tongue. Occasionally in the course of the fever there are evidences of acute or sub-acute action in all the three great cavities, and this is what occurs in the worst forms of yellow and ma- lignant fevers. In fever the functions of every organ are more or less disturbed, so that there is the best proof of universal disorder, and the appearances so frequently seen on dissection warrant this inference. True it is, that we now and then, on examining the body of an individual, find no de- cided morbid appearance.* This is by no means peculiar to the prac- tice of physic; for, in that of surgery, people sometimes die after capital operations, where there has been no loss of blood, and no or- ganic lesion found upon dissection, to explain the cause of death. They are said to die from the shock; by which term I understand that the principal functions of the body become suddenly impeded to such a degree that life can no longer be carried on. In the same way, in fe- vers, individuals die before any alteration of structure has taken place; from peculiarity of constitution, they cannot stand the shock produced by the embarrassment of so many organs in the performance of their functions; and farther, many individuals cannot bear the remedies which have been thought necessary for the subduction of the disease. Some cases of fever commence with shivering, quickly followed by increase of heat and other symptoms of pyrexia, and terminate in a few hours, after considerable suffering, by copious perspiration; this is the simplest form of fever, and is termed ephemeral; but when there is a regular succession of paroxysms, it is called intermittent. Other cases commence in the same manner, followed by heat of skin, &c.; continue for a day or two, when the symptoms decline; and there is sometimes a state of complete apyrexia, which continues only for a short time, when they recur with perhaps increased vio- lence; this kind of fever has obtained the name of remittent. When it occurs in infancy and childhood, it is called " infantile remittent" When the skin becomes yellow, the term yellow fever has been applied. Another kind of fever goes on for days, or weeks, without inter- mission, and is therefore called a continued fever. It has several va- rieties, of which the following are brief sketches. * This is seldom the case however. The only places in which the physical traces of disease can be investigated with due care and deliberation, are public hospitals, and the indifference which generally prevails is shameful. If a physi- cian has the ability, he is too much occupied; and some, unfortunately for science, have neither the ability nor inclination. FEVER. 59 First variety.—An individual feels his appetite impaired, his bow- els out of order; his urine perhaps scanty and high colored; he passes restless nights, and at length is sensible of increased heat of skin; to- wards morning he generally falls into a gentle perspiration, and enjoys a few hours sleep, from which he rises somewhat refreshed; he finds his tongue loaded, his breath more or less foetid; he feels unwell, but still is able to pursue his ordinary affairs. In the course of the day he is sensible of frequent slight chills, and flushes of heat; he becomes rather languid, has a little headache, but hopes to be better after dinner; he returns home, and although he has no appetite, forces himself to eat and drink, and passes rather a worse night. This goes on for several days, till at last he shivers pretty severely, and feels so much oppressed that he is compelled to confine himself to bed. Then for the first time medical advice is sought; the physician can find no symptom which can be attributed to inflammation; there is consider- able restlessness, but no great degree of suffering, except that which proceeds from a sense of oppression in the precordial region, fulness in the stomach and bowels, and pain in the loins; the appetite is gone, and the individual loathes food of all kinds, but has considerable thirst. The mental faculties are commonly quite sound, but there is perhaps slight alienation during the night. Abstinence from solid food, and a steady perseverance in gentle laxative medicines, soon produce an amendment. This is the form which I have denominated "Fever from functional derangement." Secotid variety.—A person is sometimes seized with a shivering more or less severe, followed by severe pain in the head, chest, or abdomen; accompanied by considerable heat, thirst, full pulse, and every symptom which announces a sub-acute attack of some structure, within one or other of the three great cavities; and this is the form all writers term a pure inflammatory fever. But when the inflamma- tion of any part runs high, it is then said to be an inflammation of a particular tissue or organ. It must be recollected, however, that in- flammation of internal organs may go on to a fatal termination with- out strongly marked symptoms. Third variety.—Another individual, without being sensible of any previous complaint, may be suddenly seized with shivering; the sense of coldness soon becomes intolerable; he is unable to support himself in a standing, or even in a sitting posture; his intellectual faculties are soon observed to be impaired, his features shrink, a deadly coldness gradually spreads over the whole surface of the body, his pulse sinks, he makes little complaint, and dies without the appearance of any of 60 FEVER. the symptoms usually termed febrile. This is a form of disease which is certainly not very frequently met with in this country, but which is often seen in warm climates, and it occasionally attacks women in child-bed. This is the purest example which can be given of what has been termed congestive fever,* but it is not that form of it which we most frequently meet in these latitudes, where it generally developes itself in the following manner:—A person, after feeling more or less unwell for some days, or perhaps for some weeks, experiences chilly sensations, alternating with unusual warmth; he is disposed to sit over the fire; feels weak, and after being in this situation for some time longer with changes from heat to cold, the cold predominates to his sensation, while another person will pronounce him to be hot; but upon careful examination, his extremities, more particularly the hands and feet, will be found cold; he makes little complaint, and is often thought to be asleep, when in fact he is comatose. Occasionally, however, the head is quite free, he suffers from slight dyspnoea, is unable to take a full inspiration, but has no pain. The tongue is gen- erally moist, sometimes loaded, white and shrunk. The pulse is soft, sometimes quick, at others not above the natural standard. Even when to all appearance he is in a complete state of coma, he can be roused, when his expression of countenance will be vacant, and appear as if he were in a state of intoxication. If questioned as to what he complains of, he will answer, "of nothing," or he will move his hand towards his head, or place it on his breast signifying some uneasiness, but he quickly falls into a comatose state again. Fourth variety.—The next form of fever of which it is my duty to give a sketch, is that in which the patient is seized much in the same way as the last described variety. He complains, however, from the first of pain in his head, chest or abdomen; has frequent attacks ol chilliness followed by heat; with symptoms characteristic of diseased action in the head, thorax, or abdomen. But this state is quickly succeeded by more or less insensibility, slight delirium, rapid weak pulse; the surface of the trunk of the body feels hot, while the extrem- ities are rather cold; the delirium which manifested itself only during the night, now becomes permanent; it is not of the furious kind, but that which is appropriately termed "low muttering delirium;" the tongue, which was moist for the first few days, is now observed to be * This is the form of fever which occurs in Rome and other places where inter- mittents prevail, and is termed fievres intermittentes pemicieuses, the pathological elucidation of which has been so fully pointed out by M. Bailly. FEVER. 61 dry and glazed; hepasses his urine and feces in bed; is always found upon his back, and however often he may be moved, will soon shrink down again towards the foot of the bed, which is a sign of complete probation of strength, and perfect helplessness, a bad symptom in any disease. In this state it is impossible to rouse the patient, and it may be evident that he is also blind; the pulse being quick, and so weak as scarcely to be felt, while the action of the heart may yet be very strong, and a considerable pulsation felt in the carotids, or abdominal aorta. Recovery is rare when the symptoms are so very severe, although the fatal period may be protracted to the end of the third week. Occasionally in this form of disease, instead of the cold predominat- ing, there is considerable heat, and symptoms are pretty sharp; but at the termination of a few days they become such as have been described above. This is the disease generally called typhus. But when the symptoms run very high at first, and subsequently become low, then it is usually called synochus. And this is precisely the form of disease which will be more particularly described hereafter, under the denomination of " a mixed form of fever," for want of a better appellation. The term typhus is objectionable, because it is sometimes used to denote a ma- ligant, or a putrid fever; at others it is employed to signify a nervous fever. The term synochus is also objectionable, for this reason, that it is stated to be of an inflammatory nature; but there is a supposed union with a typhoid state of the system, which, although present, remains latent in the first stages, and subsequently developes itself; and we are told that the appropriate remedies for inflammation are not to lie em- ployed, from a dread of typhus, which must inevitably follow. The term hectic fever is used only to signify febrile symptoms con- sequent to some previous disease, and restricted to symptoms which are produced by the formation of pus in some organ or tissue; in fact, whatever doubts have been entertained with respect to the nature of all other fevers, this is almost the only one which is universally allowed to be symptomatic. It is considered unnecessary to offer any general explanation in this part of the work respecting the fifth class, viz. Fevers attended with eruptions; or the sixth, the Plague. Causes of Fever. The causes of fever are marsh miasm, contagion from human effluvia, and epidemic influence. These causes, together with cold, fear, &c. 62 FEVER. are called, in medical language, remote; but 1 shall continue to employ the terms common and specific. Cullen resolves all remote causes into sedative, in order to support his dogma of debility; he could not consistently allow a cause of a stimulating and exciting nature. Marsh miasm, he supposes capable of producing intermittents and remittents only, and he restricts the term, contagion, to human effluvia, capable of producing continued fevers only. He considers the common causes scarcel v capable of producing fevers. Some authors assert that there is only one species of infectious matter peculiar to all febrile diseases. No one who has attended to this subject, can deny the influence of contagion, and the air of marshes, on the human body; but I conceive that too much has been attributed to them, too little to the previous state of the constitution, and also by far too little to the common causes of fever, and to internal irritations. A weighty argument in favour of contagion, is sometimes drawn from the well known fact, of fever spreading not only from one to another in a family, but also in the same tenement; but the similar circumstances under which the inha- bitants are placed should not be forgotten. The anxieties, the hopes and fears, which alternately affect individuals attending others whom they love, the exposure to cold and fatigue, the night-watching and want of rest, the irregularity in taking nourishment, and the neglected state of the bowels, all tending to produce loss of balance in the circu- lation, will go far to account for a number of individuals in the same neighborhood, and more particularly in the same family, being affec- ted one after another. Neither should it be forgotten, that all these individuals residing in the same locality, and living in a similar man- ner, may have been exposed at the same period with the person first affected, to the miasm or epidemic influence, or some of the common causes which produce fever. Why one individual should be sooner attacked than another, and have the disease perhaps more severely, it is difficult to determine. An interesting question here arises,—What length of time does the contagion remain latent in the body, before it shows its effects? This is an intricate question, and one which has never been satisfactorily investigated. Some say it can be for a few days or weeks only, while others state with great confidence, that it may remain many months. Dr. Gregory used to assert that contagion might lie frozen for any length of time, and resume its virulence upon being thawed. There are other interesting facts, which are not suffi- ciently attended to in considering this subject It is my belief, that contagion will not produce fever, applied a thousand times to a person, if he be in a good state of body and mind. Dr. Gregory stated, that FEVER. 63 he must have been exposed to the influence of contagion some 20 or 30,000 times, without affecting him once. The contagion of fever, to produce its effects, must be applied to a person ill fed and clothed, or to one whose stomach and bowels are out of order, or who is labor- ing under the effects of some mental depression. From the evidence before us in the records of medicine, it appears that individuals residing in low marshy countries, are peculiarly liable to fever which has been termed intermittent The air of a marsh, however, does not differ in its chemical properties from that of the most salubrious situations; it supports combustion, and therefore can- not, as some have supposed, be deprived of much of its oxygen. If its constitution were changed, it would affect all who breathed it, blacks as well as whites; but this is not the fact, for there are very many people, who live in the centre of marshes for years, without being attacked by intermittent fever. I have myself had many attacks of this disease during a residence in a marshy district: therefore it has been in my power to investigate this subject minutely, not only with regard to the phenomena of the disease and its causes, but also the sensations produced during the paroxysms. From personal observa- tion thus acquired, the first circumstances which attracted my atten- tion, were, that men were more liable to the disease than females,— whites than blacks,—the dissolute than sober steady-living men; and that agues were most prevalent at new and full moon. Women are less liable to the disease than men, because they are less exposed to vicissitudes of weather, their habits are not so dissi- pated, and they keep more regular hours. Blacks born in the West Indies, are less liable to this disease than whites, partly, no doubt, from the nature of their constitutions, but principally because they have neither the means nor the liberty to indulge themselves like their masters. But I am convinced that difference of constitution^ enabling blacks to resist the causes of fever better, has been very much overrated, and that diseases which destroy so many Europeans, are owing more to licentiousness than to the effects of climate. The dis- solute are more liable to this disease than others, because they often expose themselves during the night, when the system is in a state of collapse; and the disturbance which is created and kept up in the func- tions of important organs, by constant excesses, must not be lost sight of. Moisture alone has a great effect in producing disease, and its influ- ence is speedily observed on the mind as well as the body. But mois- ture alone will not produce intermittent fever, the influence of exces- 64 FEVER. sive heat must be superadded, and then there is a rapid evaporation from the earth's surface. It is this evaporation, I imagine, which is productive of so much mischief to European constitutions in warm climates, particularly where there is any tendency to collapse. Agues are not commonly prevalent during the rainy season, when the surface of the earth is more or less covered with water; but they become so after the dry season sets in, when it is alleged " the sun acts upon the soil itself, producing deep rents, whence it is supposed the miasm emanates." This, however, can be more satisfactorily accounted for in a different manner. During the rainy season, white people take greater care of themselves, and are less exposed; the sun is obscured from the eye by dense and humid clouds; there is consequently a pretty constant deposition of moisture, but little or no evaporation. The sun's influence becomes very great when the rainy season ceases, and the extent to which evaporation goes on, exceeds all belief. It is then that severe fevers and dysenteries generally prevail. Dr. Fergusson has observed, that " the same rains which made a deep marshy country perfectly healthy, by deluging a well-cleared one, where there was any considerable depth of soil, speedily con- verted it, under the dry i?igprocess of a vertical sun, into a hot-bed of disease." With regard to the apparent influence of the planetary system in intermittents, it must be observed, that in localities where this disease generally prevails, the surface of the earth is scarcely above the level of the sea at high tides; so much so, that to prevent inundations, dikes are thrown up. At new and full moon the tides rise, the marshes become covered with water, the drains become charged, and the daily effects of evaporation produce the disease. I am indeed aware, that in the interior of Ceylon, and above the Ghauts, in the peninsula of India, where the tides cannot have the slightest influence, agues are very prevalent, both among natives and Europeans at certain periods of the moon's age. 1 am informed by Mr. Marshall,* that in the in- terior of Ceylon, he has seen the mercury in the thermometer rise from 60° to 90° in the shade: and in the sun's ravs even to 14^.° The difference of temperature to which the troops were exposed from 5 o'clock, A. M. till mid-day, amounted sometimes to 82 degrees. Some have attempted to account for the occurrence of remittent fevers by the effects of excessive heat; but I believe that heat alone, *The well-known author of Notes on the Medical Topography of Ceylon- Hints to Young Medical Officers, &c. &c. FEVER. 65 unless the temperature be very high indeed, will not produce fever in any climate, till moisture be superadded, or sudden changes of weather take place, when the thermometer will suddenly fall twenty or thirty degrees, as I have myself observed in unhealthy seasons. It will be seen that it is not my intention to deny the existence of some invisible substance suspended in, or mixed with the air of the atmosphere, and which may produce intermittent fever.* A fact may be mentioned on this side of the question, which must carry conside- rable weight with it. It has occurred to me to see a good deal of in- termittent fever in situations far remote from marshes, but in every one instance the individuals had been at some period of their lives in marshy districts; yet it is certainly very strange, that some of them never had a paroxysm during the period of their residence in these places, and not till months, and in some instances years, had elapsed. Some contagious diseases are communicated from person to person, by breathing the air in the apartment where the sick person is con- fined; others require that actual contact should take place; and some diseases are communicated in either way. In the plague, it would appear that actual contact with the affected individual, or with his ap- parel, is necessary; whereas, in small-pox, the contagion may be re- ceived merely by coming into the same room, and it is also conveyed by inoculation. Contagious diseases spread slowly from one person to another, and from house to house, and may often be concentrated with- in a circle, where it will attack all or almost all, who are exposed to the contagion, particularly those who have not had the disease before. When we say a disease is epidemic, it is understood that we mean one, which is produced by a certain state or condition of the atmos- phere at present unknown, and which has baffled the exertions of every one who has entered upon its investigation. The term implies that a great number of people are suddenly seized at the same period. An epidemic, after continuing for a longer or a shorter period, suddenly ceases, at a time perhaps when the greatest number of patients are affected with it. These are facts which appear to have confounded those who assert that yellow and other fevers are invariably conta- gious. It appears to me that intermittent fever is never contagious: but I am of opinion the yellow fever, and that which has been termed typhus in this country, are so, under particular circumstances, in a very high • Some writers go the extraordinary length of speaking of the specific gravity of Marsh MLisin. Vol. I.—fl 66 FEVER. degree. Observation and experience have induced me to conclude, however, that this cause of fever has been very much overrated. In the year 1793, Dr. Chisholm made an attempt to prove that the fever which then prevailed in the West Indies, was highly contagious, and imported from Bulam on the coast of Africa, by a ship called the Pfankey. Similar attempts have since been made in many places in America, as well as in Europe, to account for the severe fevers which have prevailed from time to time. The favourers of importation have invariably failed in proving the disease to have originated in that man- ner, and have not been able to show that it had not a local origin. In the town and garrison of Gibraltar there are always cases of fever, particularly in sultry weather; many are severe, attended by yellow- ness of the surface of the body, and vomiting of a dark-coloured mat- ter commonly called black vomit. These cases are considered by all candid observers to be the ordinary remittent fever, common to this and all other places under similar influences. The majority of the cases are found to occur in the lowest, worst ventilated, and filthiest parts of the locality. But in 1804-1810-1813-1814, and 1828, Gib- raltar was visited by a fever more severe in its symptoms, more fatal in its results, and attacking a larger proportion of the troops, as well as the inhabitants. On each of these occasions attempts were made to prove its importation, and that it spread by contagion, and had no trace of local origin. Considerable doubts were, however, entertained upon this subject; but in 1S14, the supporters of importation and con- tagion failed so completely in showing the foreign origin of the fever which then prevailed, that many sensible people were led to doubt, and others to deny, the truth of such views. I wish at present to con- fine my observations to the source of the fever which prevailed in the town and garrison of Gibraltar in 1828. A host of medical men, with the late lamented Dr. Hennen at their head, maintain that the disease was of local origin, for which there were abundant sources, and that there is no proof of its havino- been imported. One or two others, with Sir William Pym, superintendant-general of quarantine, as their leader, not only insist that it was not of local origin, but that it was imported in a particular ship called the Dygden, which sailed from Havanna, on the 12th May 1S2S, and arrived at Gibraltar on the 28th June. I have carefully perused all the evidence produced through the me- dium of the medical periodical press, and published by the following gentlemen:—Mr. Frazer, late surgeon to the civil hospital at Gibral- FEVER. 67 lar; Dr. Smyth, surgeon 23d regiment; Mr. Amiel, surgeon 12th Regiment; Mr. Wilson, late of medical staff, who, I believe, retired from the service partly from disgust, and partly from the persecution to which he was subjected, and would not submit; Dr. Barry, physi- cian to the forces: also Sir William Pym's replies to queries put to him by the royal medico-chirurgical society of Cadiz,—together with opinions of the board of commissioners,'and certain document- ary evidence respecting the annual occurrence of fevers of a similar character at Gibraltar, as extracted from the books of the civil hos- pital, and authenticated by the signatures of a number of highly re- spectable gentlemen. After the most careful perusal of these productions, duly consider- ing all the facts adduced in evidence by all parties, my deliberate opinions are as follow: 1st. That the fever of 1828 was of local origin, and for which there were unfortunately abundant sources in the bad state of the drains, the crowded condition of the poorer inhabitants, and the exceedingly filthy and badly ventilated state of their abodes. 2d. That there is not a tittle of evidence to show that the disease was first propagated by communication with the Swedish ship Dyg- den. Indeed, it does not appear that there was any cause to suspect this ship of bringing the seeds of the disease with her from Havanna. In the first place, we see from her clean bill of health, signed by the authorities there, that " this city and its neighbouring towns are free from all plague or contagious epidemic disease; as likewise the said captain, with the fifteen men of his crew, are in a perfect state of health, according to the muster by his roll," &c. In the second place, we find the declaration of the captain, and the report of Dr. Hennen to the governor, the first of which bears that he "sailed from Havanna on 12th May, with a crew of fifteen men, all in good health. A few days after two men of the Swedish part of the crew complained of severe headache, and pains in the limbs, which increasing, they had to go to bed. Through sudorifics and purging medicine, they got well in ei"-ht days, so as to be able to attend their duties. During that time, five others had been taken ill of the same complaint, but recovered in a few days, under similar treatment. A lapse of ten or twelve days followed, during which the whole crew were in perfect health; but upon getting into a higher latitude, I met with gales and rain, when the greater part of the crew suffered much from wet, and immediately after those who had till then been well were taken ill, probably from cold produced by the weather, yet the symptoms which appeared were % 68 FEVER. the same as in the others. The youngest recovered in a short time, but the oldest two died, one after five, the other four day's illness, which took place on the 27th May, and 1st of June. The old clothes they had worn, together with hammocks, and what was in them, were thrown into the sea with their bodies." In Dr. Hennen's report to the governor of Gibraltar, dated 2d Au- gust, 1828, we find it stated, that he had minutely inspected the cap- tain and crew, " whom I found in perfect health, and I shall repeat my inspection before the expiration of their quarantine, on the 6th of the present month. In my letter of the 29th July, I mentioned, as the reason for putting the ship in quarantine for forty days, that two men died on the passage. It is now sixty-six clear days since the first man died, and sixty-one since the death of the last, and nothing like disease has since appeared, nor have I the most distant reason to ap- prehend danger to the public health, from any circumstance connected with the Dygden. 3d. If the disease were contagious, it does not appear from the evi- dence to have been so in any high degree. 4th. It is an undoubted fact, known to every medical man who has been upon the rock, that remittent fever, attended by yellowness of skin and black vomit, is a very frequent occurrence during the au- tumnal months. I am in possession of an authentic document, con- taining a history of the symptoms and appearances on dissection, ob- served in cases of remittent fever treated in the civil hospital at Gib- raltar in 1821, and the five subsequent years. Having compared these with the cases of 1828, I can discover nothing different The two symptoms pitched upon by Sir William Pym, as pathognomonic of true yellow fever, viz. yellowness of the surface and black vomit, were present, and the morbid appearances found after death were perfectly similar. The superior medical officers have had a heavy charge made against them in the following statement by Dr. Smith. " At one period of medical rule in this garrison, every variety of fever was ordered to be returned under one head. Such, indeed, was the thraldom of the mili- tary medical press (if I may so use the expression) at Gibraltar, from. the termination of the epidemic fever of 1814, until the arrival of Dr. Hennen in 1S26, that it was considered a most wicked heresy for a surgeon of a corps to return fevers under any other head than simple continued fever. The consequence is, that although febrile diseases are the most frequent of the numerous cases treated both in the mili- tary and civil hospitals, no correct table of fevers can be now formed FEVER. 69 from the returns of these establishments; no distinction whatever being drawn between the different species of remittent and continued. The authors of such a measure can best answer for themselves." Was this done to deceive the govenor, or did it receive his approbation to mis- lead the authorities in England? This calls aloud for serious investi- gation, in order to prevent the repetition of such disgraceful manage- ment. That it could have been endured, can scarcely be believed, ex- cept by those who, like myself, have been exposed once or twice to the tyrannical conduct of ignorant and obstinate medical superiors. 5th. That Sir William Pym's answers to the queries of the Spanish physicians, are highly discreditable to him as a scientific man, and cal- culated to injure the public interests, however much they might be intended to fix him in the receipt of the salary derived from his sine- cure office of superintendant-general of quarantine in Great Britain. These answers are for the most part vague assumptions—some being drawn from insufficient evidence—others from no evidence whatever —while many of them are at complete variance with fact, of which last, the following is a notable example:—Answer to question 3d. " The first cases were, as I have said, in a house of 24 district, the situation of which, is healthy, very well ventilated, and 200 feet above the level of the sea." Now it was in this district of the town that the fever avowedly first appeared, and was for some time con- fined. Whether it was such a healthy, well-ventilated spot, or one, the air of which was saturated with febrific poison, the reader is left to draw his own conclusions after the perusal of the following state- ment, copied from a document which I received from Gibraltar. It was not written to contradict Sir William Pym's answer, as it never entereil the writer's imagination that the superintendant-general of quarantine, or any other gentleman who had resided at Gibraltar, could have hazarded such a statement. The district in question (No. 24) " is situated in a natural gorge of the mountain, and is rendered still more close by a high wall raised for the military protection of the town. The wall is called < Charles the 5th wall,' and is situated on the south of the town. The rear of the district, (24) together with the whole town, is impenetrably shut out from the influence of east winds by the rock itself. The district itself is particularly cut off from the beneficial effects of perflation by a high and impending semi-circular bluff of the mountain, in some de- gree insulating it from the rest of the town, on the north side. Charles the 5th wall is higher than the tops of the buildings in this district. This locality is therefore excluded from the influence of 70 FEVER. every direct wind, unless that which blows from the west, which was not the case when the fever broke out. Besides, it is deserving of par- ticular attention, that the superficial soil was filthy, that the district is intersected with numerous collateral drains, and gives origin to seve- ral others which unite on the level below, and these form one main sewer which disgorges itself into the sea at water mark, directly in front of this part of the town. The wind enters the mouth of this sewer on the beach, rushes upwards through the drains, and escapes through gratings (which are closely concentrated in this district) loaded with offensive and noxious exhalations, and diffused within a limited circle among the houses erected round the mouths of the great branches. There is also a deep and large common soil-pit in this dis- trict, which at the commencement of the epidemic was filled with im- purities of every kind. In this situation a drain burst about the be- ginning of September, in the barrack-yard of the 12th regiment; and when I saw it, its contents had broke up the solid pavement, and was boiling over. The atmosphere of this part of the town was conse- quently noxious, and contained within itself a sufficiency of putrid mat- ter to have disseminated a febrific miasm over the whole garrison. Now, it is a remarkable fact, that the two first cases of the fever ori- ginated on the ground floor of a badly ventilated house in this district, and in the close neighborhood of one of the openings of the drains; and about 50 of the cases in the beginning of the epidemic were dis- tinctly traced by several medical officers to come from the vicinity of the openings of the drains and privies of this district, or in the course of the drains." We find the following statements made by Dr. Hennen, in his offi- cial communications, which I have copied from Dr. Smith's paper: " That so many cases of fever of a very serious nature have appeared in the barrack of the sappers and miners, on Hargrave's parade, which I would observe to your excellency is in the line of the drains, cross- ing from district No. 24, that I feel myself called upon to submit the propriety of immediately encamping that corps, and totally evacuating the barracks." In another letter to the governor, Dr. Hennen fur- ther stated, " In reference to my letter of this day's date, I have mi- nutely inspected district No. 24, in company with Mr. Wilson, of the f civil hospital, Mr. Woods, the medical officer attached to that district, and other staff-officers; and it is with much regret that I have to state to your excellency, that at every step I took in that district, I had reason for surprise, not that fever had broken out there, but that it had not extended farther. From whatever causes it may have proceeded, FEVER. 71 the pauper population is dense to a degree incredible, except to those who have seen it. In sheds without ventilation, without drainage, and generally composed of the slightest materials; in tiers of beds as close as in a crowded transport, numerous individuals sleep. They go out to their work at an early hour, and return at gun-fire, locking up their miserable places of noctural shelter during the day, and leaving them saturated with the steam of their bedding, their food, and the over- flowing receptacles of their ordure. The detail would be too disgust- ing to enter into; but I most respectfully submit to your excellency, the indispensable necessity of sweeping away the whole of these sheds, which I have every reason to suppose are unauthorised by the govern- ment." A commission was subsequently appointed by the governor's orders, to inspect the different districts of the town, which was com- posed of military as well as medical officers, and I copy the following statement from their report: " In the course of our inspection, we were struck at every step we took, with the density of the population.'' So much for Sir William Pym's answer to the 3d question, in which he has given a confident assurance of the healthy situation and well- ventilated state of No. 24 district, where the first cases of fever oc- curred in 1828. Both statements cannot be true, and I am sorry to say there are many other points in the same predicament. I wish it were possible for me to reconcile them with each other, not only on account of the reputation of Sir William Pym, as an old officer, but for the credit of the department to which he belongs, and the judgment, of the authorities who appointed him to the lucrative situation of su- perintendant-general of quarantine in Great Britain. 6th. It is my opinion that the Board of Commission was not happily chosen by Sir George Murray. No medical officer should have been nominated, or any other individual, however exalted his rank, who had previously expressed decided opinions on the subject to be investigated. 7th. I humbly conceive Sir George Don, the governor, acted con- trary to his orders, and certainly he did not act wisely, by delegating his authority as president of the commission, to any individual, and more particularly to Sir William Pym, the superintendant-general of quarantine, who immediately nominated his newly-acquired parti- san Dr. Barry to be secretary to the commission. That Dr. Barry is an ingenious gentleman is well known; that he changed his opinions very suddenly at the time of Dr. Hennen's death is alleged, and has not been satisfactorily disproved; and that he immediately adopted the opinions of his new chief is undoubted. That Dr. Barry, in his capa- 72 FEVER. city of secretary, gave colouring to the evidence produced before the commission, or improperly put leading questions to the parties exam- ined to favour the views of his chief, I do not mean to state. But it will be admitted, that such functionaries as president and secretary should not have been chosen from a class of persons to whom the slightest suspi- cion could be attached. On the list of the commission, I find another name as those of Sir William Pym and Dr. Barry, viz. that of Dr. Broadfoot, superintendant of quarantine at Gibraltar. Besides these, there are also the names of two official gentlemen, the captain of the port, and the town major, who were thus improperly placed in a situation either to accumulate or reject evidence, which might show inattention or dereliction of duty to such an extent as to compromise their situations! The only unexceptionable appointments on the com- mission were those of Colonel Chapman, civil secretary, and Judge- Advocate Howell,and the coincidence of their opinionsis quite remark- able. Colonel Chapman's opinion is as follows:—Judging from the evi- dence produced before the board, the manner in which it has been given, together with the description of persons who have been brought forward as witnesses, I am decidely of opinion that the late epidemic disease is of local origin. As to the importation of the late epidemic, I am of opinion that the attempt to prove the introduction of the dis- ease, after many months of fruitless inquiry by those who wish to prove it, has totally failed." Judge-Advocate Howell gave the following opinion: " Upon a careful review of all the proceedings before the board, I am of opinion, that the evidence brought forward has totaly failed to prove that the late epidemic disease was introduced from any foreign source, either by the ship Dygden,or by any other means; and I am further of opinion, that the late epidemic had its origin in Gilbraltar." From Botta's History of Tuscany, the following statements are ex- tracted respecting the epidemic yellow fever which prevailed in Leg- horn in 1804. " It was occasioned, as it appears, by the prevalence, during the summer of that year, of south winds, unusually warm and rainy; this sickness was by some termed the yellow fever, by others the black vomit; both names which agree well with the symptoms which mark it. // began to rage in the lowest quarters of the city and those most crowded and filthy, to such a degree that some were cut off in seven days, some in five, others in three, and even in the short space of one day." " The disease was most violent in robust young men, more mild with the weak, the old,and with females; but almost all FEVER. 73 those last, attacked when pregnant, died; almost all the children escap- ed." Speaking of the remedies, it is remarked, "On the other hand, it was found, that from the air being impregnated with animal exhalations, the disease was more easily propagated, and the person infected was more violently attacked; and a confirmation of the argument was found in the circumstance, that the quarters of the city most filled with filth, and the houses of the poor, were the chief seats of the dis- ease. On the contrary, the airy quarters, and where the houses were neat and clean, and enjoyed open and free air, were either exempted, or did not become worse, or the infection did not spread from one body to another." "It did not extend into the country, although persons in numbers, and goods in quantities, were transported and spread from district to district, and from the city to the country." On this occasion, also, an attempt was made to prove the importation of the fever from Vera Cruz, but was not successful. When the yeilow fever prevailed in Philadelphia in 1793, the cele- brated Dr. Rush was most shamefully persecuted by the authorities, to whom many of his medical brethren lent themselves, for having proved that the yellow fever existed in that city—that it was generated in the place, and had not a foreign origin. It is now nearly forty years ago; and after reading the report made on the subject by his opponents, I can readily join Dr. Rush in his conclusion, that "it is impossible to review this report, without blushing for the shameful submission made by the science of medicine to the commercial spirit of the city." It may be useful to my readers to know the evidence which Dr. Rush produced to show the local origin of the fever; and it will be observed, that an attempt was made on this occasion to fix its importa- tion on a ship. "It was produced," says Dr. Rush, " by the exhalations from the gutters and the stagnant ponds of water in the neighbourhood of the city. Where there was most exhalation, there were most persons aflected by the fever. Hence the poor people, who generally live in the neighbourhood of the ponds in the suburbs, were the greatest suf- ferers by it. Four persons had the fever in Spruce street, between Fourth and Fifth streets, in which part of the city the smell from the gutters was extremely offensive every evening. In Water street, be- tween Market and Walnut streets, many persons had the fever; now the filth of that confined part of the city is well known to every citizen. On the 25th August, the brig Commerce arrived in the river from St. Mark. Alter lying five days at the fort, she came up to the city. A boy who had been shut out of his lodgings, went iu a stats of intoxica- Vol. I. —10 fc 74 FEVER. tion and slept on her deck, exposed to the night air, in consequence of which the fever was excited in him. This event gave occasion, for a few days, to a report that the disease was imported; and several physicians, who had neglected to attend to all the circumstances that had been stated, admitted the yellow fever to be in the town. An in- vestigation of this supposed origin of the disease soon discovered that it had no foundation." Vitiated air,* and the effluvia which proceed from the bodies of in- dividuals crowded together in jails, hospitals, and ^hips, have always been abundant sources of fever. Dr. Fordyce mentions instances where sheep and hogs were transported during the American war, from England to America, in the holds of ships, in which many were con- fined in a small space; an infectious fever frequently broke out among them, which destroyed great numbers. History affords many melancholy examples of the baneful effects of vitiated air and human effluvia, and the speed with which they destroy animal life. The best example is to be found in the occurrence which took place last century in the black hole at Calcutta. One hundred and forty-six unhappy individuals were forced into a dungeon, about eighteen feet square, at eight o'clock at night, and at six next morning, when released, only twenty-three came out alive; most of these were in a high putrid fever, and subsequently died. It becomes an interesting question, but one too extensive for this work, how contagion propagates itself, and to which part of the body it is first applied? In this inquiry, we shall be much assisted by the circumstances which are observed to take place after inoculation with small-pox. The mucous membrane of the lungs seems to be one of the first parts in which the diseased action is to be detected; and care- ful observation has induced me almost to believe, that in diseases pro- duced by contagion, the bronchial membrane rarely if ever escapes. Fourcrois tells us, that in several of the burial grounds in France, in which the graves were dug up sooner than they ought to have been, the persons employed have occasionally been asphyxiated; those who were standing at a little distance, were often affected with vertigo, fainting, nausea, loss of appetite, &c. History affords us remarkable instances of the occurrence of disease* decidely epidemic; the most ancient are those which will be found in sacred writ, in which we find, that on one occasion seventy thousand persons were destroyed by pestilence in three days' time; and we are told, also, that one hun- * It is to be regretted that the term malaria is not restricted to foul air, accord- ing to its literal meaning. FEVER. 75 dred and eighty-five thousand persons were destroyed in the Assyrian camp in a single night. The most remarkable epidemic of modern times, is the Cholera of the East, which extended itself in the very teeth of tempestuous winds. Pythagoras first started an opinion respecting critical days, and he had an unlimited belief in the occult powers of certain numbers. Hip- pocrates seems to have entertained similar opinions, and it is an essen- tial part of the old doctrines of concoction, according to which it was supposed that a separation of the morbific matter had a tendency to take place on one of the critical days, by a discharge from the skin, bowels, kidneys, or blood vessels. I have no belief in the influence of critical days, although I admit that the crisis frequently takes place in some of the ways mentioned. When an organ is affected with disease, there is a constant effort of nature to throw it off; this effort is, in truth, one of the great princi- ples of life, and its object is effected by a determination of blood to an- other organ; occasionally a spontaneous discharge of blood takes place. From the time of Hippocrates, it has been generally believed that fevers had a tendency to remit on the 3d, 5th, 7th, 9th, 11th, 14th, 17th, 20th days, and even on the 21st Many modern physicians have adopted this doctrine; but I doubt much whether it has not proved more injurious than beneficial in the treatment of disease. Often may physicians be seen prescribing a placebo, because the critical day is at hand, when they ought to be actively employed in eradicating the dis- ease. When attending to this point, I have very often found the cal- culations made erroneously; and not unfrequently I have seen physi- cians disagree as to which was the proper critical day—one calcu- lating from the period when the rigor took place—another from the period when the heat of skin occurred—and I have seen a third calculation made from the time when the patient confined himself to bed. There can be little doubt, that fevers and other diseases have a tendency to run through a regular course, and when they terminate favourably, this happy event generally takes place upon the occurrence of an eruption, or of some discharge, as by diarrhoea, copious perspira- tion, flow of urine, expectoration, &c. It cannot be denied, however, that in some diseases there is a strong tendency to periodicity, but far more so in the accession than termination. Thus, in intermittent fever, the attack may come on regularly at the usual period, but each stage may occupy a shorter or a longer space of time in one paroxysm than another. Sometimes an individual dies in the cold fit, but much oftener the hot fit is not relieved by sweating, and his disease becomes 76 INTERMITTENT FEVER. a continued or remittent fever, or inflammation of a particular organ takes place. But it is of little importance whether the doctrine of critical days be true or false, if the physician acts wisely, and neglects nothing which can tend to reduce the diseased action. INTERMITTENT FEVER. Of all the febrile diseases, intermittent is generally the simplest in form. ' It is composed of three stages, beginning with a cold fit fol- lowed by heat, and terminating in profuse perspiration. It has been known from the earliest ages, and is most prevalent in some parts of North and South America; the Pontine marshes near Rome; in Hol- land; and in the fens of Lincolnshire and Cambridgeshire in England. We are told, that in the sixteenth century this fever was very prevalent, and proved fatal to a great number of people in London; and in the year 1558 it raged like the plague, and was also very fatal; but it has become less frequent in Great Britain, which is to be ascribed to the increased comforts of the people, to their habits of cleanliness, and to the im- provement which has taken place in the climate, owing to the drain- ing of lands, and cultivation of the soil. It has been stated, but, I believe, without foundation, that a miasm producing intermittent fever is generated in London in the neighborhood of St. James's Park. In- termittent fever is of very frequent occurrence in all warm countries, and is one of the purest specimens of a disease depending upon an ir- regular determination of blood, in which the system is often relieved by the unaided powers of the constitution. Cullen's definition is, " Fevers arising from marsh miasmata, con- sisting of many paroxysms, with intermission, or at least with an evi- dent remission intervening, returning with remarkable exacerbation, and in general with shivering; one paroxysm only in a day." Like most symptomatical definitions, this is very exceptionable. Pa- roxysms of intermittent have taken place from sudden change of at- mosphere in situations where no miasm ever existed; and the most severe cold stage which ever came under my notice, and which lasted twenty-six hours, was produced by exposure to frost after the indivi- dual had got wet on the top of a coach. Mr. John Hunter informs us, that two children had ague from worms; they took bark, but it did them no good; but the worms were destroyed, and they got well. We have, in like manner, says he, agues from many diseases of parti- cular parts, more especially of the liver and spleen, and from an indu- INTERMITTENT FEVER. 77 ration of the mesenteric glands. Many instances are also recorded from repelled eruptions, the drying up of old discharges, as well as from the application of cold. Sir George Baker has given an account, in the Medical Transac- tions, of an intermittent that prevailed in 1780; it affected the inha- bitants who lived in the higher parts of the country, while those in the marshes escaped. Sir Gilbert Blane informs us, that while the village of Greenhythe, nearly on a level with the marsh at Northfleet, is unaffected with intermittent fever, the adjacent hills suffer consider- ably from them. There are usually reckoned three kinds of intermittents, the tertian, quotidian, and the quartan. But they ought strictly to be regarded as the same disease, with a longer or a shorter interval; and the one frequently runs into the other. We often, however, see a double quo- tidian. I have observed, that the longer the interval, the more severe is the paroxysm, and vice versa; but there are many exceptions. Tertian is employed to express that form of disease in which there is an interval of forty-eight hours from the commencement of one at- tack to that of another; quotidian, twenty-four; and the quartan, seventy-two. [Other forms—reduplications of these—are occasionally observed in the United States. As, for instance, double and triple tertians. The former may be mistaken for quotidians, a paroxysm occurring every day, but varying in intensity, time of access, duration, &c. every other paroxysm will, however, be similar. The latter exists, when two paroxysms occur every other day, and a single one on the inter- mediate day. Innumerable types are described in the systematic treati- ses upon intermittent fever. We once witnessed the return of a single paroxysm every two weeks, for three months in succession; and with the utmost difficulty it was at last prevented.] Phenomena of Intermittents. When an individual has once had an attack of intermittent fever, he is afterwards more liable to the disease, and is sensible of its ap- proach some time before any one suspects him to be ill; the toes and the last joints of the fingers feel cold and benumbed, and the nails have a blueish color; he has sensations of languor, and long fits of yawning; occasionally at this period there is headache, sometimes stupor, and pains in the back and loins. Cold Stage.—When the paroxysm actually commences, the patient I 78 INTERMITTENT FEVER. feels the extremities cold, with a sensation as if a small stream of very- cold water were flowing down the spine, which extends itself to the thorax and abdomen. He has great desire for warm drink, and to cover himself with as many bed-clothes as can be procured; the pros- tration of muscular power is considerable; the sense of cold very soon becomes insupportable; the teeth chatter, and there is an universal tremor over the body; and if I can trust my own sensations, and the acounts of others, the tremors affect internal as well as external parts. These tremors sometimes terminate in convulsions. The respira- tion is always laborious, short, and hurried, and the individual is un- able to take in a deep inspiration when desired; a short hard cough frequently attends, without expectoration; there is great oppression at the praecordia. Some individuals complain most of headache, some of pain in the back, in the lumbar region and lower extremities, and others of universal pain. In almost all cases the patient is incapa- ble of attending to any ^thing. Sometimes there is stupor, and at others, coma or delirium. The features are much shrunk and pale; the eye looks dull and hollow, while the cheeks and lips are more or less of a livid hue. The pulse is oppressed and weak, sometimes slow, at others quick, and frequently intermits; but the violence of the tre- mors renders it often impossible to feel the pulse distinctly. The tongue is moist. It is a curious circumstance, that while the patient complains of intense cold, the heat of the body every where, except in the extremities, is sometimes above the natural standard. The paroxysm occasionally comes on without any rigor, instead of which the patient feels a slight sensation of cold, or severe headache, is lethargic, or affected with languor and yawning. Sometimes the paroxysm is announced by violent articular, lumbar, and frontal pains; and sometimes a patient falls into a profound sleep for several hours, and awakes in a violent hot stage. These various forms are called by the vulgar the dumb-ague. It sometimes happens, that at the next attack, instead of a regular paroxysm, a violent pain is felt in the sit- uation of the supra-orbitary foramen, and extends to the brow, affect- ing the nervous twigs of the frontal branch of the fifth pair: this pain often continues for many hours, and seems to resemble the tic doulou- reux. But it would be vain to attempt a description of all the appear- ances which this disease occasionally assumes. The duration of the cold stage is very various, rarely less than half an hour, and seldom exceeding four. It sometimes happens that an icy coldness steals over the whole surface, and in aguish countries it is not an uncommon circumstance for persons to die in the cold stage. INTERMITTENT FEVER. 79 Hot stage.—After the cold stage has continued for a longer or short- er period, the hot stage commences; the one gradually runs into the other, there being no distinct interval between them. The change is attributed by patients themselves to the treatment which has been em- ployed, or to the effects of vomiting which sometimes accompanies the cold stage. The skin becomes hot and dry, and sometimes pungent; the face flushed and swollen; the thirst urgent, the tongue parchedj there are restlessness, and oppression at the prsecordia; the respiration is hurried and anxious; and almost invariably, the patient complains of acute pain in some region of the body, generally in the head and lumbar region, very often also in the thorax, and left hypochondrium; there is frequently a slight degree of disturbance in the mental facul- ties, sometimes indeed delirium. On some occasions there are symp- toms, which announce cerebral disturbance, viz., severe headache, tinnitus aurium, and throbbing of the carotids. The pulse is fre- quently quick, sharp, and bounding, even in patients whose health and strength are already much impaired. I have seen the thermometer, the accuracy of which had been well ascertained, rise in the hot fit, even in this country, to 110°, and in warm climates it is stated to rise as high as 120°. The duration of this disease varies more than the former; in general it continues from four to twelve hours, and terminates in perspiration; but on some occasions the febrile symptoms continue for several days or weeks, when the disease is termed a continued fever; now and then there are marked remissions followed by exacerbations, when it is called a remittent: in addition to the last-mentioned circumstances, there are sometimes considerable irritability of stomach, black vomit- ing, and a yellow tinge of the skin, then the case is termed a bilious remittent, or yellow fever. Sweating stage.—After the hot stage has continued for some time, it terminates in the sweating stage; the perspiration appearing first on the forehead, arms, and legs, soon becoming general and profuse. It is difficult to calculate the quantity of this excretion in any case; but it is admitted by all who have attended to the phenomena of intermit- tents, to be very great. From the moment the perspiration begins to appear, the uneasy sensations, and other symptoms above described, begin to subside, and generally vanish after it becomes copious.* * M. Andral, in the first part of his very excellent pathological writings, p. 477, mentions a very curious case. A young man, who had been hemiplegic on the left side of his body from his infancy, was attacked with tertian intermittent. He only perspired on that half of his body which had not been paralysed. He 80 INTERMITTENT FEVER. Many patients fall into a profound sleep for several hours, and then awake quite refreshed; others complain much of weakness, while some whose constitutions have not been previously injured, are able to resume their ordinary duties almost immediately. When this disease continues for some time,'the patient not only be- comes weak, and loses flesh, but he has no interval of ease; each pa- roxysm increases his sufferings, and he feels comparatively little relief from the perspirations, which he often prolongs, in the vain hope of alleviating his symptoms. He complains of headache, intolerance of light and sound; or he has a cough and dyspmea, which will almost always be found to depend on inflammation of the lining membrane of the air passages; or he has constant thirst, flatulency, constipation, or diarrhoea, with griping pains in the bowels, a dull pain and sense of weight in both hypocondriac regions, generally in the right; the skin is hot, and feels harsh; the feet and legs frequently become oedematous; the abdomen tumid; the urine scanty; the tongue dry at the tip, the rest of it being furred; the patient passes restless nights; and perhaps in the very next paroxysm he may die in the cold stage; or the sweat- ing stage may not succeed the hot, and he may die in a few days of continued or remittent fever; or decided marks of inflammation of the brain, liver, lungs, &c.,take place, and he is cut off, from tne effects of disorganization in these organs. Such circumstances are of frequent occurrence in warm countries, where intermittents, prevail. Many such melancholy examples will be found, by referring to the works of Sir John Pringle and others; but more particularly to Sir James Fellowes's reports of the destruction occasioned by this fever among our troops employed in the expedition to Walcheren. The history of the fever which annually prevails at Rome, and which has been so ably and faithfully described by M. Bailly, also corroborates the above statements. This fever sometimes attacks individuals when labouring under in- ternal diseases, such as dysentery, hepatitis, &c.,and I have frequently seen a remittent converted into an intermittent. It may also be men- tioned, that enlargements of the parotid take place during the course of intermittents. The gland increases in size and hardness during each cold fit, and it seems, in the first instance at least, to owe its en- largement to sanguineous engorgement; subsequently the gland sup- purates. stated that, in his best health, he never perspired but on one arm and leg, and on one side of his face and nirk. INTERMITTENT FEVER. 81 It has already been mentioned, that when intermittents have con- tinued for some time, the^Jpwer extremities frequently become cede- matous, the belly tumid, and sometimes even ascites take»jplace. The first does not denote danger, but the last always occasions an appre- hension of an organic lesion of some important viscus. Nevertheless, both may be occasioned by mere functional derangement. In these cases, the thirst is considerable, and the secretion of urine scanty, and sometimes dysenteric symptoms manifest themselves. •Appearances found on Dissection. The following appearances have ,been observed in the bodies of those wlib died in the cold stage.—The vessels of the brain gorged with venous blood; and the carotids, after passing into the skull, may sometimes be seen greatly distended with black blood.—The lungs much congested, of a dark colour, which* is the condition described by thejplder writers, by the term "putrid state." In the very few instan- ces which have fallen under my own^observation, I have not observed any structural disease in these organs; for, upon making sections, and squeezing them in water, they have resumed their natural appearance and buoyancy.—The heart, and veins near it, are gorged with blood; and sometimes an effusion of blood or bloody serum, is found in the cavity of the pleura. In the abdomen dark-coloured patches are sometimes seen on the peritoneum', occupying a considerable extent of the intestinal tube; and, upon cutting through these portions, all the tissues are found highly injected, and it is probable that this ap- pearance has often been mistaken for mortification.—The liver is sometimes gorged with blood and discoloured; but when treated, like the lungs, in water, this organ'is restored to its natural colour, unless it has been altered in structure by previous diseased action, when it is easily broken down, like coagulated blood. I have seen the spleen in the same state; but was not able, by washing, to restore it to its na- tural appearance. The'"stomach and intestines contained, in one in- stance, a dark sanguineous-looking matter, like the black vomit. In corroboration of the above statement, as well as in proof of the pathological a*hd practical views yet to be detailed, I beg to subjoin a short account of some of the interesting cases and dissections describ- ed in the excellent work of M. Bailly,* whose zeal in the cause of • Entitled Traite Anatoraico-Pathologique des Fievres Intermittentes, Simples et Pemicieuses 1825. Vol. I.—H 82 INTERMITTENT FEVER. science, led him to Rome in the sickly seasons, for the purpose of investigating thenature and seat of intermittent fever. "Case I.—Benoit Simouelli, set 30 years, of a strong constitution, affected for some time with a tertain fever, came to the hospital on the 2d July 1822. , ., "3d, Had a slight febrile access, afterwards took 5 ij. of bark. "4th, Towards mi(J-day, he walked in the ward, felt very well, and laughed with the other patients.' All of a sudden, he was seized with violent shivering, to which succeeded a very high fever, during which he had alternate flexion and extension of the fore-arms, and proround coma. He died in six hours after the commencement of the attack. "Dissection the following day at 2 o'clock p.m.—Vivid injection of the whole of the arachnoid; colour of. the cineritious matter of the brain much deepen than natural, approaching a dark reddish grey; a little water in the "ventricles. No false membrane on the arachnoid. Great inflammation of the stomach, especially towards its great cuoya- ture, which was every where of a deep, generally diffused red. Many worms in the small intestines, which presented also inflamed portions, especially where the ascarides had collected. "Case 111.—Pierre Donati,aet 2S,of a good constitution, was brought to the Hospital of Saint Esprit, on the 2d August 1822. "An hour and a half after mid-day, he was seized with an accession of fever, which commenced by excessive coldness, followed by intense heat, and stupor. He lay upon his back, with his eyes half open. He awoke when any one spoke to him, and fell again inty> the same state of coma. His pulse was frequent and strong; the skin burning. In the night copious sweating appeared, the intellectual faculties re- turnecj, and in the morning he was in a state to answer concerning his health. Took several ounces of bark. "3d, The fever returned half an hour aftefc mid-day. Commenced with a very violent coldness, followed by heat, and stupor; but never- theless he always awoke when any one called him, and he opened his eyes. The fore-arms were bent upon the arms, and, could not be extended; the teeth clenched, which prevented the state of the tongue from being seen. Sensibility of the skin diminished. He lies upon his back. There is no pain upon pressing the belly. At half past two o'clock general perspiration, but not so abundant as the first In the evening, return of sensibility and intelligence. Cessation of contrac- tion of the arms. But the ideas are less clear. Other doses of bark. INTERMITTENT FEVER. 83 "1th, The morning of the third day after his arrival, at half past 7 o'clock; the pulse was frequent; stupidity; together with a drunken appearance. At 11 o'clock: a return of the cold, subsequent fever more violent; stupor more profoundfcoma, retirn of the rigidity of the limbs, subsultus tendinum; he always lies\ipon his back; pulse full and strong. At half past three o'clock, sweat appeared, but less copi- ous. After the sweat, he could* not give an answer, and he was un- conscious of his own state; cessation of the contractions. Died at 10 o'clock in the evening of the 5th. "Dissection 12 hours after death.—Lively inflammation of the whole of they arachnoid; serosity between the circumvolutions, with engorgement of the vessels; injection oflhe vessels of the lyra. The brain being raised, there escaped half a pound of blood. Some points of^.ared colour in the stomach and intesignes; liver gorged with blood; spleen voluminous and easily torn. No morbid appearance in the chest ♦ t "Case IV.—Francois Lauretti, shoemaker, aet 60, of a lean consti- tution, fell sick on the 17th August 1822. He had the fever every day, beginning with shivering, and termiiAting in the night by sweat- ing. At the same time he was constipated, and had pain in the epigastrium. Was brought to the Hospital of Saint Esprit on the 24th August. In the evening, the surface of his whole body was of a deep yel- low citron colour; said this colour appeared during the last paroxysm; extremities cold, while he had a feeling of internal heat; tongue red and dry; pulse 108, like a thread. He had still so much recollection, that he smiled ohy seeing us approach him, for we had already spoken to him when he was brought to the hospital, and* before he was yet put to bed. He complained of nothing, appeared quite tranquil, and replied perfectly to all that we asked him. **25th.—In the morning he was found in a state of coma; and died at 10 o'clock, a. m. "Dissection. The body was of a lemon yellow colour. On opening the head, the^dura mater was tinged as yellow as the skin; by repeated washing this tint could in part be removed; but on holding it to the light, the diminution of colour was scarcely perceptible; injection of the arachnoid; cortical substance of a deep colour; yellowish serosity between the convolutions. On slicing the brain, a number of red points were seen; a little water in the ventricles: the cerebellum natural; the lungs healthy; the cavities of the heart appeared to us larger than usual; in the right ventricle, was a clot entirely formed of 84 INTERMITTENT FEVER. i albumen, as yellow in colour as that of the skin and dura mater. The belly, before being opened, was concave, and restitig on the ver- tebral column; the stomach contracted on itself; it was every where of the colour of lees ot wine. Although it was well washed, there ad- hered to its surface a thick mucus, similar to the tenacious expectora- tion of patients labouring under pulmonary catarrh. The smaller curvature, and a portion of the greater, presented that kind of eruption described at No. 30. When examined with a lens, it offered nothing , more remarkable than to the naked eye, only instead of appearing to consist of small perfectly round elevations, and entirely separated from each other, they communicated by their bases. 4 The redness of the stomach was less lively towards the pylorus, but it began imme- diately at the duodenum, where it was very intense, and continued without interruption in' the small and large intestines. The gall- bladder was green externally, and filled with a black and thick bile; on pressing it strongly, only a few drops could be made to pass into the duodenum; the orifice of the ductus choledochus could not be distinguished, in the midst of the red, bloody, and swollen folds of the mucous membrane of the duodenum, but by this means. The ductus choledochus being opened,presented nothing remarkable, except that its mouth was drawn into the duodenum, in consequence of the swell- ing of the inflamed tissue of the latter. The liver was of ordinary consistence; its colour was of the yellow of powdered bark: this is the only time I ever saw it in this state. The spleen was of the usual size, and quite diffluent "Case V.—Jean Oliver, set 40, of a good constitution, was brought to the hospital on the 6th July. He was then without fever. In the evening the fever came on, preceded by shiverings, and followed by violent heat. Pulse strong, 120; coma. He lies upon the back. Right arm immoveable. The left arm bent and carried towards the head. Sensibility every where. WThen an attempt is made to open the left eye, he appears to experience pain, and contracts the eyelids. Belly painful. "7th, in the morning.—Coma; lies upon the back; pulse strong, 108. He died at seven o'clock, r. m. "Dissection.—Injection and thickening of the arachnoid; engorge- ment of the vessels which run on the convolutions, which are separa- ted by watery exudations; the left lyra greatly injected; watery effusion at the base of the brain; phlegmonous eminences in the stomach, which were of a grey slate colour; invagination of the small intestines; spleen voluminous and pulpy. INTERMITTENT FEVER. 85 "^"Case VI.—Vincent Orsini, set 60, came to the hospital the 3d July 1822, in the following state: Coma; pulse insensible; extremi- ties cold; demi-flexion of the two thoracic extremities; when an at- tempt is made to extend them, a resistance is felt on the part of the flexor muscles. Left eye half shut, right eye open, pupils dilated, immoveable; tongue dry, lying in the very bottom of the mouth. He manifests pain when pressure is applied to the belly. Died the same evening. "Dissection.—Vivid inflammation of the arachnoid, with great in- jection of its vessels. There escaped some serum, which was situated between the dura mater and arachnoid. A fibrous tumour, of the size of a large nut, adhered to the dura mater, under the posterior angle kof the pariejpls, and compressed the brain: although the injection of the arachnoid was very lively on both sides, it was, however, great- est on the left. Hydatid in the choroid plexus, the size of a small pea. The water that was between the arachnoid and dura mater was more abundant on the left side than on the right; brain pretty soft General inflammation of the stomach; the S. of the colon was of a brownish red. " ^Jase VII.—Donato Fanti, a collier, aet 50, was brought to the Hospital of Saint Esprit, in a comatose state, which continued even until death. Pulse strong, beating 80 times in a minute; when the extremities were pinched, the patient manifested pain, his skin was hot and moist; when they opened his eyes, he did not direct them to any object It was impossible to see his tongue, because his jaws could not be separated sufficiently. He only complained of pain when he was pressed in the region of the liver, and did not appear to suffer any thing when pressed on any other part of the belly. "Dissection.—On opening the cranium several ounces of blood es- caped; the arachnoid was strongly adherent to the dura mater by granulations resulting from old inflammation; the vessels of the brain were very much engorged; on slicing it, drops of blood escaped from the divided vessels, which reappeared even after wiping. The liver was blackish; it appeared composed only of black blood, slightly coagulated, and of cellular bands, which alone offered some resistance to the finger: where this weak resistance was overcome, the liver was but of the consistence of thin jelly; for the blood appeared effused in its tissue, which resembled a pulpy mass. The intestines were in- flamed in several points, and each inflamed portion corresponded to some knots of worms which were still alive. The lungs, the spleen and the stomach were healthy. 86 INTERMITTENT FEVER. " Case IX.—Joseph Totti, horse doctor, of a sanguine bftious tem- perament, strong constitution; was accustomed to go down every year to marshy situations, to direct the workmen in seed time, or at the harvest, which occasioned obstruction in the spleen and liver. In 1811, in the time of harvest, being then aged 40, and working with great activity, he was affected with an intermittent fever, which con- tinued till the third paroxysm. At last he returned home; the fatigue of the journey procured for him a very short sleep. I saw him in the fifth paroxysm, when he was in the following state: Agitation; im- possibility of finding a position which procured rest; pain under the right false ribs, mounting to the top of the shoulder, and extending to the left hypochondrium; pains in the articulations; head heavy; tongue covered with a white crust, bitter taste in the njouth, vomit- ing, thirst; face livid; pulse irregular, neither soft nor hard; great difficulty in respiring; urine red and clouded. He got an injection to loosen the belly. He had little repose during the night, for the fever returned, preceded by a general coldness over all the extremities, and the pain in his side was aggravated. "6th day.—A frequent dry cough without expectoration. The emulsions had eased the thirst. Had no appetite. The bitter taste in the mouth had disappeared. A pound of blood was drawn fro/n the arm, the coagulum was almost soft; the serum was livid. At the re- turn of the fever, the cold only attacked the extremity of the feet. " 7th day.—The pain worse and worse; the difficulty of respiring still greater; frequent eructations; urine always the same. As the tongue was white, and as he had had no stools after the lavement he took Ei of manna, which produced a bilious stool. In the night he had no sleep; delirium. " He became gradually worse, and died on the fourteenth day, when in the act of raising himself to speak to his confessor. " Dissection.—The body offered nothing remarkable but ten- sion of the belly. In the abdomen, there was sanious effusion mixed with a little blood. The liver was putrid and tuberculous; this affec- tion commenced towards the convex part, extending itself on all sides, and descending towards the concave p?rt; nevertheless, the greatest destruction was on the convexity; the rest was engorged and inflamed; its volume was natural. The gall bladder contained a little thin clear bile, not viscid. The inferior face of the diaphragm was erysipelatous; the stomach and small intestines were full of water; the spleen double the ordinary size, and of a black colour; the exterior surface of the right lung was covered with a white crust, the inferior part adhered to the pleura costalis. INTERMITTENT FEVER. 87 . ► "Case X.—Dominique de Marco, ait 30, of a good constitution, was affected with a simple tertian fever since the 24th June 1822. On the evening of the 7th July, he was seized, according to the report of his parents, with an accession of the pernicious comatose intermit- tent He arrived at the hospital on the morning of the 8th of July, and he was in the following state: Coma; decubitus on the back; face red; fore-arms bent and contracted; pulse 112; convulsive trembling of the fingers; legs stretched and immoveable; sensibility every where. They made him swallow three ounces of bark in six hours. "At 2 o'clock.—Pulse 100; sinapisms to the feet " 9th,^n thejnorning.—He is in a sweat; remission of the fever; „ pulse 88; a watchful coma; he hears, but does not answer, although he looks; two hours later, pulse 92, very full; several ounces of bark. "Evening.—Pulse full, strong, 96; profound coma; resisting stiff- ness of the rfght arm; he cannot show his tongue; skin hot, and al- ways moist with sv^jat To make him swallow the bark, it was ne- cessary to pinch his nose, and hold his mouth open with a key; after- wards water was poured in, which he kept in his mouth, and finished by rejecting it He has taken seven ounces of bark through the course of the day. " 10th, in the morning.—Pulse 140, strong and full; coma; flaccid- ity; general immobility; mouth open; blood was taken from the jug- ular; respiration stertorous. Died towards mid-day. " Dissection.—Injection of all the vessels of the arachnoid, even to the very smallest ramifications, and on both sides; but on the right side, and upon the anterior lobe, it was of an intense red, without any distinction of vessels; when it was torn away from the convolutions, thepia mater was also removed; it adhered so intimately to the arach- noid as to resemble one membrane, red, very thick, and in the tissue of which blood was effused, which appeared immediately to coagulate; little water in the ventricles; the brain of the ordinary consistence; when it was cut, there appeared a great number of red points, which immediately became the seat of large drops of blood; the arachnoid of the cerebellum was also highly injected, the consistence of that organ was natural. Stomach grey, externally contracted, slightly in- flamed; small intestines presented two invaginations; a portion of this intestine white, transparent, distended with gas; the rest grey and con- tracted- in three places all the circumference of the tube is red, both within and without, occupying the space of three inches inJength; all the large intestine is white, &c. &c. Liver gorged with blood; spleen weighed between two and three pounds, and reduced into a grey, pulpy state." 88 INTERMITTENT FEVER. "Case XL—Paul Tossini, aet 30, of a good constitution,was taken on the morning of the 29th of June with a fever, which commenced with heat, and which returned every day untiljthe 6th July, when he arrived at the hospital. He had had thirst, bloody stools, tenesmus, enlarged spleen; and he had taken cooling drinks and a purgative. He is now in the following state: His appearance is stupid; somno- lence rather than coma; general pain of head. .The patient only appears to be drowsy, for he is easily awoke, and understands suffi- ciently well what is said to him; decubitus on the back, the knees are drawn up, but he cannot extend the thighs without experiencing pain; during his slumbers the right eye is partly open, the left shut; it is impossible to depress the lower jaw, without producing suffering; the tongue is dry, red, covered with a black crust, which extends from the point towards the middle, the breadth of which is not more than half an inch; the tongue is drawn a little to the right; at intervals, slightv convulsive movements of the hands; pain of belly upon pressure; skin hot,dry; pulse 120. When the right arm is extended the flexor muscles contract, and the patient seems to suffer much pain; but when once extended it continues so. " In the night, bloody dejections, extremely fetid; declination of the paroxysm, which returned on the 7th in the morning; at seven o'clock the patient complained of cold. I did not see him till six o'clock in the evening, when the paroxysm was beginning to decline; the skin was hot and moist; the lips were encrusted; the pulse was not to be ' felt; respiration hurried; the two fore-arms bent, when it was wished to extend them, above all the right, violent pain was produced; pre- servation of sensibility, every where; sometimes the right eye a little open, the left being shut. He had several convulsive movements this morning and towards mid-day. He took kino before the accession at the moment when he already felt the cold. Increase of coma; died at half past seven o'clock in the evening. " Dissection.—General injection of the arachnoid, particularly that part which covers the cerebellum and the lateral part of the com- mencement of the spinal marrow. The injection of the right side was a little more intense than that of the left, although it was other- wise as vivid as it is possible to imagine, for it was not a simple injec- tion, which merely shows the smallest vessels. The arachnoid was of a deep red, as if all its tissue were penetrated with blood. The b/ain presented.nothing remarkable. The intestines were injected in trie same manner, from the oesophagus even to the anus; their whole thickness appeared to be impregnated with blood; they were not either thicker than natural, nor contracted; on the contrary, they were INTERMITTENT FEVER. 89 distended with flatus. Spleen weighed from eight to ten pounds; when it was put upon the table it became flat like a bladder half filled with water; its tissue was reduced to a pulp."- "Case XIII.—Francois Pompeii, set 19, was seized on the 1st July 1822, with an .accession of fever, in consequence of a sudden chill which he experienced on entering a cool grotto when his body was covered with sweat. He was brought to the hospital on the 2d July, at six o'clock in the evening. Before he arrived, he had a considerable epistaxis. He was in the following state; profound coma, eyes widely opened, directed to the right, fixed; expression besotted; general im- mobility; decubitis on'the back; insensibility of the extremities when pinched, they were quite flexible. He did not answer the questions which were put to him; the direction of the eyes did not change even when one approached him. He manifested pain when his stomach was compressed; skin burning hot; a white oedematous swelling of the face; his parents said that this tumefaction had come on since the disease, for previously he had rather a thin face. This access contin- ued until Wednesday morning the 3d July; he then took an ounce and a half of bark. " 4th July, Thursday morning.—The paroxysm returned, at the commencement of which, he could still give answers to the questions put to him, but the coma went on increasing, and with it all the symp- toms above described; the pulse was strong, vibrating, full, beating 84; the same direction of the eyes to the right, the same immobility of these organs, and of the extremities; respiration short. Eight leeches to the ears; died at ten o'clock in the evening. " Dissection.—Several ounces of blood flowed from the nose in the dead room; in cutting the scalp, more blood escaped; the whole might have weighed a pound. General engorgement of all the vessels which ramify upon the convolutions; the brain, still covered by the dura mater, gave a feeling which made us believe that there was a fluid in the interior, nevertheless there was only a little serosity in the ventri- cles; the substance of the brain was of the natural colour. All the intesti- nal tube, without any exception, presented a red appearance, which was owing to a general injection of all the vessels, even in their smallest ramifications. It would be difficult to inject so perfectly the vessels either of the intestines or of the mesentery, as they were in his body. The intestinal tube, although a little transparent, was pene- trated with this congestion throughout its whole thickness; every Vol. I.—12 90 INTERMITTENT FEVER. thing indicated the first stage of a violent inflammation, that is to say, of a sanguineous congestion." "Case XV.—Thomas Adami, set 20, was brought to the hospital on the 23d August, 1822. He was delirious; they were obliged to secure him. After mid-day the delirium subsided. A profound and intense coma succeeded; the pulse was strong, hard, and beat 85; the extremities were flexible, but motionless; decubitis upon the back; pupils immoveable; features swollen and intensely hot; general insen- sibility. Body covered with a clammy sweat In the evening the respiration was more hurried, and very much embarrassed; pulse not to be felt; froth was discharged from the mouth; he was insensible even when his skin was pinched; died at one o'clock in the morning. " Dissection, eleven hours after death.—General inflammation of the arachnoid, of which the very smallest vessels were injected; no se- rosity; the cortical substance was of a deep red, compared with that of a subject dead from a shivering fever, (lafiivre algide,) which we shall notice by and by, &c. &c." " Case XVI.—Antoine Turianne, set. 12, of a good constitution, was brought to the hospital on the 23d July, 1822,at four o'clock in the after- noon. He was in the following state: Commencement of stupor, his an- swers are slow,and not quite correct; the questions putto him made him discontented and unhappy; agitation; he turns himself on all sides in his bed; eyes open and stupid; skin hot and dry. (Bled to 8 oz.; lavement; tisane.) In the evening, increase of stupor, in consequence of the accession of another paroxysm; coma profound, eyes open, pu- pils contracted and immoveable, the fore-arms bent upon the arms, no pain on pressing the belly. Sinapisms to the feet. "24th July, in the morning.—Continuation of coma; pulse 124; head intensely hot; flexion of the fore-arms; it is impossible to depress the inferior jaw. Bled at the feet to 8 oz. In the evening remission of the fever and of the convulsive symptoms: skin slightly moist; it was necessary to pinch his nose to make him swallow oij. of bark. " 25th, in the morning.—Return of the fever, and the flexion of the fore-arms; continuation of the stupor; does not reply to questions; in- sensibility of the skin of the legs, that of the arms sensible; head in- tensely hot; decubitus on the back; eyes open. Boiling water ap- plied twice to the feet; the patient did not feel it very acbtely. Pediluvium during six minutes; snow applied to the head; the pulse fell to 82. Return of intelligence, he swallowed voluntarily the bark; INTERMITTENT FEVER. 91 but a little afterwards, violent agitation of all the body came on; the inferior extremities, which from the commencement were cold, were neither heated by the bath, nor inflamed by the application of boiling water and sinapisms. Of the four ounces of bark which they made him take, he vomited more than two; neither could he retain the bark injections which were exhibited. He remained in this state till 6 o'clock in the evening; the coma returned, and he died at 7 o'clock. " Dissection.—A very vivid injection of all the arachnoid; between its folds there was a membrane produced by the coagulation of effused blood; much serum between the convolutions, and at the base of the cranium; the cortical substance very red. The stomach natural; the small intestines contained a prodigious collection of worms; the in- flammation was sufficiently intense in this part. The colon was con- tracted, its walls very thick, and the internal membrane much inflamed, of a dark red color." " Case XXX.—Joseph Maoloney, set about 60, came to the hospital on the 21st September 1822. He had been sick for five days. His answers were so confused, it was impossible to find out what had been his previous state, further than that he said he had vomited some bitter stuff, that he was tormented by thirst, that he had suffered great dis- tress, and had pains in the epigastrium. In the evening, tongue dry, vividly red round the edges; constipation, nausea without vomiting, heat natural over the extremities and the thorax; a burning heat in the epigastrium; anguish, severe pain in the stomach under pressure; pulse small, frequent; lavement of barley water—gum-water—fomen- tations to the belly. During the night, vomiting, and had a stool. "22d, in the morning.—Pulse more expanded; the ideas still con- fused, diminution of agitation; heat natural every where; tongue dry; thirst. Same treatment. About half-past 9 o'clock he had vomited the tisane with mucus, bile, and several lumbrici. About half past 11 o'clock, stupidity, pains in the epigastrium increased. At 3 o'clock p. m. lancinating pain of belly; pulse small, frequent; extremities cold, and bathed in cold clammy perspiration; inferior extremities bent up upon the belly. Bled from the arm, died in half an hour afterwards. " Dissection.—Injection of the vessels which ramify upon the con- volutions of the brain; substance of the brain presented an infinite number of small drops of blood; three or four ounces of water at the base of the cranium; lungs natural, crepitating. In the belly there were fifteen or sixteen ounces of dark blood, running like oil; spleen ruptured at its inferior part, not by a fissure as in other cases, but pre- 92 INTERMITTENT FEVER. senting an opening the size of a dollar, out of which came a dark and putrilaginous substance; it was impossible to raise the spleen without breaking it, it was so diffluent; it separated in the hand into two por- tions, of which one when placed on the table became flattened like jelly, and the other portion remained attached to the diaphragm, which they were obliged to cut out to expose the spleen completely; it was not much increased in volume. The stomach was of a reddish brown in the greatest part of its extent; inflammation of all the rest of the intestinal tube; rose-colored within; bladder natural; liver gorged with blood." " Case XXXVIII.—Angelo Galetti, set. 18, of a good constitution, was brought to the hospital on the evening of the 29th July. The patients who were near him said, that during the night he complained continually of sharp pains in the belly. Took an ounce of bark; the whole of the body was as cold as ice. " 30th, 8 A. M.—Legs, thighs, fore-arms, arms, cheeks, of an icy coldness; the belly, chest, and forehead were of rather a lower tem- perature than other parts of the body; pulse insensible at the wrists; I could feel it but very feebly in the crural arteries, it beat 100; the pa- tient trembled and complained continually; his most common position was on the left side, with the thighs bent on the belly. He understood what questions were put to him, but not sufficiently well to give proper answers; he never entered into any detail; and died at half- past nine. " Examination three hours after death.—The small intestines slightly distended with gas, were externally of a purplish red. The internal membrane was of the same colour, so that the violent injection of which the)' were the seat, had existed through the whole thickness of the substance of the intestine. This injection was recent. Inflam- mation of the upper half of the caecum. The whole of the great intes- tine was white externally; on being opened, it presented an inflamma- tion, the violence of which was greater towards the rectum, where the mucous membrane was so intensely inflamed, that some blood had been effused, which mixing with the mucus, formed a thick coating which adhered to the whole of its surface. The colour of all the interior of the colon, and especially of the rectum, was of a lively, intense red: in a word, the most violent degree of inflammation that can exist with- out disorganization. The stomach was pale after being washed; it pre- sented, near the pyloric extremity, an infinity of little depressions from half a line to a line in diameter, and some of which contained in INTERMITTENT FEVER. 93 their bottom a small spot of blood, which was easily removed. The folds of the mucous membrane were, besides, nearer each other, and more numerous than ordinary. The mucous c*oat itself was thickened. The liver was healthy. The spleen large and pretty hard, but of a redness of the lees of wine. Slight adhesions of the right lung; the same between the whole surface of the heart and pericardium; they were easily destroyed. Injection of the arachnoid, engorgement of the vessels which ramify on the convolutions, and of those which com- pose the choroid plexus. "Case XXXIX.—Vincent Crescenzi, set. 60, of a thin but healthy habit of body, fell sick on the 19th of August, 1S22. He was attacked with fever, which set in with shiverings, followed by extreme heat, pain in the head and belly, vomiting of bilious matter. During the night, the paroxysm terminated in sweating. He was brought to the hospital of Saint Esprit on the 19th August, 1S22. The fever returned in the morning, preceded likewise by shiverings, and accompanied by the same symptoms as in the evening; the stomach was painful on pressure; the patient experienced a ereat heat in the inside; anxiety; depressed countenance, the features were as if flattened to the bones of the face; the colour of the face was natural, the expression dull.— (Half an ounce of bark on the decline of the paroxysm.) " Evening.—Decline of the symptoms; skin wet with a cold clammy sweat; pulse small, frequent; general shivering; pain at the epigastrium; tongue red, but moist; no thirst. (Half an ounce of bark.) "Night.—The skin remains moist and cool. The patient has vomi- ted the bark. "He had several paroxysms afterwards; became worse, and died on the night of the 2;>d, sensible to the last, v "Dissection.—Slight injection of the arachnoid; engorgement of the vessels which ramify upon the convolutions; an effusion of yel- lowish serum between the foldings of the arachnoid; cerebrum and cerebellum natural; heart and lungs healthy. Stomach grey externally and contracted. Inner surface of a bright red, deeper still towards the pylorus. Foldings of the mucous membrane better marked than usual. Small intestines grey externally, and contracted. Internally, their redness was brighter than that of the abdominal muscles, which afforded us a point of comparison. To give an idea of this inflamma- tion, the colour of the large intestines could be compared to that which they would receive were they soaked in black blood. This inflamma- tion increased as it approached the S. and the rectum; liver healthy; 94 INTERMITTENT FEVER. spleen of a middling consistence, between the state of degeneration and health. This inflammation could be compared only to that of the 30th case." " Case XL.—Vincent Cola Paolo, of Rimini, aet 40, of a good con- stitution, residing at Roma Vecchia, entered the hospital on 7th July. Had been attacked with a paroxysm of fever on the previous evening. On the morning of the 7th, his state was the following:—Hands colder than those of a dead person; pulse 108, small, contracted; hiccup regu- lar in its returns fourteen times in the minute; position supine; sighs drawn easily; answers pretty correctly; he experiences pain in the region of the liver. In the evening, the fit declined, and the hiccup disappeared. " On the morning of the Sth, senses completely restored with his natural expression, which, during the paroxysm, assumed that particu- lar aspect which characterises those labouring under the fever; but the hands have always an icy coldness, which extends half way up the fore- arm; he is not aware of their being cold; but on placing them on his belly, he at once becomes sensible of it; he speaks as if he were in a state of health. At nine o'clock, his appearance became as if besotted; he replied with hesitation and reluctance. Has an inclination to sigh. He lay on the side, with the legs bent upon the abdomen; the fit commenced, the cold gained upon the trunk, respiration became short, some tendency to hiccup; in short, he died at three in the afternoon. He took some bark during the apyrexia. " Dissection.—General injection of the arachnoid, which is thicker than natural, red, and as if doubled by a sanguinolent false membrane; the vessels distributed upon the circumvolutions of the brain are en- gorged; the stomach is much inflamed in its pyloric half, the rest of the intestinal canal healthy." "Case XLI.—Angelo Donni, of Milan, set. 35, weak, lymphatic constitution; preparer of macaroni. On the 5th July, 1S22, he en- tered one of the grottos of monte Testaccio, when he experienced a general sense of cold, which he attempted to shake off by drinking seven or eight glasses of wine; but could not, however, warm himself. He then felt a great weakness, which was the predominant symptom during the six days previous to his entering the hospital. His state had so little of a decided febrile character, that, according to his ac- count, the medical man could not tell him if he had had the fever. He had a sense of general uneasines; took an emetic and a purgative, INTERMITTENT FEVER. 95 and returned to his work; but the general state of disease and uneasi- ness increasing, as likewise the weakness, on the 11th of July in the morning he came to the hospital of Saint Esprit, on foot, supported by a man on each side. Being arrived in the 1st ward, where 1 first saw him, he seated himself upon a form, and appeared to feel ill. He let himself fall down upon the right side, but the expression of his countenance was not that of a person fainting. There was something in the motions of his head, of his eyes, resembling those symptoms produced by drunkenness, and not that want of power occasioned by the cessation of the motions of the heart He was merely supported, and recovered, and he was then enabled to ascend more than 30 steps, in order to reach the clinical ward. When in bed, the following was his condition; pulse frequent, weak; temperature of thighs, legs hands, and arms, cold; tongue moist and not red. He was able to give a history of his previous state, nevertheless he begged the physician to question his companion, who accompanied him to the hospital, for although he had neither delirium, nor coma, nor syncope, he appeared so confused, so little master of his ideas, that he declined to give any account of it All he assured us of was, that he had never had the fever. In the afternoon he was twice ill. "Evening.—Pulse scarcely perceptible, great pains, extremities cold, the left hand more so than the right; it is of a livid colour. Tempera- ture of the belly, and the chest, almost natural; face pale, delirium, agitation, inquietude. (Decoction of bark 3 viij. Extract of bark, theriaque, a a. gjj. Laud. liq. anod. camph. emuls. a a gr. xx. blisters to the thighs.) " 12th July.—At half past one in the morning, sweat general and copious, but cold. In the morning at the visit, weakness the same; pulse insensible at the arms, which are cold, as also the thighs; the belly is a little warmer, but it is also below the natural temperature; pulse at the temples 114. The blistered surface pale, no water under the epidermis, which remains only detached. He has lost no part of his judgment, but manifests a tendency to drowsiness, complains of no pain; the belly is not tender on pressure; the principal ailment is great weakness. (Blisters to the arms. Bark ^ij in wine.) " A little later, return of the same symptoms, alternating with deli- rium and drowsiness; general and intense sense of cold; died at half- past five in the afternoon. " Half an hour after his death, the body was warmer than during life. " Dissection.—Stomach highly inflamed between its great curvature 96 INTERMITTENT FEVER. and the pylorus. Intestines presenting traces of inflammation in some points. Spleen soft and pulpy, liver healthy, old adhesions of right lung. Before opening the cranium, the head was separated from the trunk, when there escaped by the occipital foramen a great quantity of bloody serum. Injection of the arachnoid in its minutest ramifica- tions, but a little more on the left than on the right side. Great en- gorgement of the vessels distributed on the circumvolutions, more marked on the left side. Grey substance of the brain of a pale, rather than of a deep hue; choroid plexus pale; serosity between the circum- volutions; brain of a soft consistence." From these and other cases it appears, that M. Bailly found in thir- ty-three dissections, more or less extensive disease in the brain: in twenty-two of these there was thickening, and other marks of inflam- mation, in the arachnoid coat; and in eleven, inflammation of the sub- stance of the brain. In twenty cases there was gastro-enteritis. In four cases gastritis by itself, and also four of enteritis, uncomplicated with gastritis. In eleven the spleen was softened; in some instances enlarged; one weighed from two to three pounds, and another from eight to ten pounds. In two cases the spleen was large and hardened. In three cases the spleen was ruptured, and in one it was gorged with blood. In two cases the liver was softened; in four gorged with blood; and in one case inflamed. In one case the gall-bladder was inflamed. In two cases there was pericarditis. In three, peritonitis. In one, pneumonitis. In one case there was inflammation and enlargement of the parotid. These statements respecting the appearances on dissection in inter- mittent fever, will be found fully corroborated in the works of Mor- gagni, Pringle, Cleghorn, Chisholm, and Fellowes. Causes of Intermittents. In point of form, I ought now to treat of the causes of intermittent fever; but having explained myself so fully on this subject, when treat- ing of the causes of fever in general, at page 71, it is unnecessary to do so in this place, further than to repeat my conviction, that the ef- fects of internal irritations, sudden variations of temperature, and of evaporation, as causes producing intermittents, have hitherto been too much overlooked. INTERMITTENT FEVER. 97 Pathology of Intermittents. As there are three distinct stages in this disease, it will be proper to treat of the pathological condition of the body during each. Cold stage.—Perhaps the first link in the chain of morbid action may be in the nervous system; there is decided evidence of its being involved from the beginning to the termination of the disease. But as there is nothing to guide us in the investigation, I shall not enter into it. The first circumstance which we distinctly perceive, is di- minished circulation of blood in the extremities, then a sense of cold- ness, and with it a feeling of weakness. These are evidences of an irregular determination of blood, by whatever cause produced; and in proportion as blood accumulates in the vessels of internal organs,* their functions become impeded. The lungs show their gorged state, by the short, difficult, and anxious breathing; by the impossibility of inflating them beyond the least degree; and by the violent dry cough which occasionally takes place. The livid appearance of the cheeks, lips, and mucous membrane of the mouth, is an additional proof of the embarrassed state of the lungs, showing that the blood is not pro- perly de-carbonized. The disordered functions of the brain in this stage, depend, I imagine, principally upon the gorged state of the lungs, and also upon the overloaded state of the right side of the heart, preventing the free return of blood from the head. The disordered functions of the brain may also be produced by a change in the balance of the circulation of the vessels of the head, independently of the state of the lungs and heart The tremors may probably be attri- buted to congestion of the vessels of the brain and spinal marrow. The sense of cold seems to be owing partly to the state of the nervous system, and partly to the state of the lungs. The pain in the head and loins, and oppression at the praecordia, may be fairly attributed to the same causes. The muscular prostration, and feeling of sinking, are not owing to actual debility, but to obstructed action, in conse- quence of the above-mentioned condition of organs. The proof of * This is the state termed congestion, which implies, that the balance between the arterial and venous system is deranged for the time, the latter being overload- ed or congested with blood; and not that the circulation in any organ, or set of or- o-ans, is entirely obstructed, which nevertheless does actually happen in those ex- treme cases in which re-action does not take place, and the individuals die in the cold stage. Vol. I.—13 98 INTERMITTENT FEVER. all which circumstances is to be found in the fact, now well known, that abstracting blood in the cold stage, will immediately remove not only the difficulty of breathing, the pain in the head and loins, the disordered functions of the brain, (when these exist,) the oppression at the prsecordia, &c, but will also stop the rigors, restore the strength of the pulse, increase the heat of the body, and cause the sensation of cold to vanish in an instant. Cullen and others believed, that all the subsequent phenomena of fever depend upon the cold stage, which, although a mere hypothesis, is now for the first time proved to be true. The pathological views which are still taught in most of the schools of Great Britain may now be stated, and this shall be done in the words of the late very celebrated professor of physic, Dr. Gregory: " The languor and debility depend upon diminished nervous energy; the uneasy feelings, on muscular debility; the paleness of the face and extremities, and shrinking of the features, are owing to spasm of the extreme vessels; the coldness is to be explained by the blood being propelled from the surface by debility, or prevented from entering the vessels by the spasm; thus the cold may be produced either by the spasm or by the debility; the tremors depend upon debility of the muscles, but there is also some irregularity of nervous energy; the breathing during the cold stage is small, frequent, and anxious, owing to debility of all the muscles that serve for respiration, while, at the same time, the congestion of blood produced by the weakened action of the heart, would require the breathing to be often repeated, and the respirations to be fuller than natural, which circumstance tends to in- crease the uneasiness; the heart partakes also of the debility; this de- bility of the heart produces an accumulation of blood in the great ves- sels, ai«l this occasions that unusual motion of the organs of respira- tion, termed yawning. Want of appetite, nausea, and vomiting, are owing to debility of the fibres of the stomach. Costiveness is pro- duced partly by spasm. Failure of attention and memory, and also delirium, are owing to debility." On perusing these statements, the reader will observe sufficient proof of the pathological condition of the body; which I have described but instead of attributing it to the same state of organs, he places spasm and debility as the cause of each phenomenon; thus most unphiloso- phically, like the rest of the disciples of the Cullenian school, he makes the facts to suit the doctrines. Influenced, as this distinguished man's mind was, by such erroneous pathology, it is no wonder that he should have pronounced the following dogma: " I have no doubt, therefore," said he, " that the causes producing fever, act first by inducing debili- I INTERMITTENT FEVER. 99 ty; and accordingly we find, that stimulants employed at this period have produced good effects in checking this disease, while evacuations, as blood-letting, which at another period of the disease might have been proper, if employed in ihz first stage never fail to be attended with most dangerous consequences; or it is, to use the words of Celsus, " hominem jugulare." I shall now show that this is a statement which Celsus never made with reference to the cold stage of intermittent On a careful refer- ence, I find no allusion made to such a practice in his works; but in treating of the danger of bleeding in vehement fevers, he expresses himself thus,—" Quod si vehemens febris urget, in ipso impetu ejus sanguincm mittere, hominem jtjgtjlahe est." Lib. ii. cap. 10. It appears to me that Dr. Gregory was led into this error by a statement made by Sir John Pringle; who, in allusion to the good effects of bleeding in the camp fever which he describes, observes at page 210, (Observations on Diseases of the Army, Ed. 1768,) "A person unac- quainted with the nature of this disorder, and attending chiefly to the paroxysms and remissions, would be apt to omit this evacuation, and to give the bark prematurely, which might bring on a continued in- flammatory fever. A vein may be safely opened either during the remission or in the height of the paroxysm; for besides that I have observed the remission to come sooner and fuller after hemorrhage, I have repeated experience of the safety of bleeding in the hot Jits; and not only in this, but in the marsh fever, even after it had come to almost regular intermissions. In order to make Celsus's maxim (he quotes the above passage from lib. ii. cap. 10,) consistent with this practice, we must interpret his terms impetus febris in the sense of that chillness or cold fit which preceded the hot one in the* fevers which he describes; for then indeed bleeding toould be improper." This is straining an author's statement to suit other views with a vengeance. The meaning of Celus is clear and precise,—he makes no allusion to the cold stage. This shows how liable we are to be misled by the authority of a name. Hot stage.—Acting upon the principle of not inquiring into occult cau>es, very little need be said respecting the circumstances which produce the re-action; but there has long existed a pretty general belief that the blood accumulated about the heart, in the cold stage, proves a stimulus to that organ, and produces re-action. In this man- ner Dr. Gregory and others make the spasm of the extreme vessels the cause of the diminution of blood on the surface; and then he ob- serves,—"The blood thus driven upon the internal parts, must ac- cumulate in, and prove a stimulus to, the heart and great vessels." 100 [intermittent fever.] The next question comes to be, how is this effected? The truth is, that we know nothing of the matter; and, after all, it is perhaps best to attribute it to "the principles of life" or, in the language of Cullen, to the "vis medicatrix natura," which is ever in action, to prevent injury, and to remedy the evil after it has occurred. The phenomena which are ascribed to the state of re-action, are those, the combination of which is denominated fever; namely, hot and dry skin; quick pulse; thirst and loss of appetite; restlessness and anxiety; headache, and occasionally delirium; hurried respiration; dry, furred tongue, &c. With respect to the heat and dryness of the skin, the old opinion of Boerhaave need scarcely be alluded to, who attributed this condi- tion to the friction of the globules of the blood against the sides of the vessels; neither is it necessary to dwell upon the still older opin- ion, which attributed the heat to fermentation; nor is it requisite, after what has been previously stated in this work, to say a word more respecting spasm of the extreme vessels. The heat and dry- ness of the skin in the second stage of intermittent are, no doubt, owing partly to the suppression of the secretions and excretions; also, probably, to some change in the nervous system, but principally to the increased quantity of blood driven to the surface of the body. Sweating stage.—It has been stated that, in general, in cases in which no organic lesion exists, the pains and uneasy feelings begin to subside after the commencement of the sweating, and soon after- wards disappear. An interesting question here presents itself: how does the perspiration produce the effect? It appears to me that it acts in two ways; first, cooling the body by evaporation; and, secondly, it moderates the force and frequency of the heart's action, by deplet- ing the system. It is impossible to stale the precise quantity of fluid perspired in such cases; but. if I can trust the hasty, and far from accurate, observations made respecting this point, by placing oil-skin on the outside of the bed-clothes I am inclined to believe that it amounts to considerably more than two pounds; and it must be kept in view, that this discharge comes directly from the blood itself. [The pathology of intermittent fever has ever been a vexed ques- tion in medicine, nor shall we here attempt to solve it; at the same time, we propose to give a brief view of those modern doctrines, which, originating with the French pathologists, have been more or less adopted wherever medicine is cultivated. The physiological school apply their idea of irritation, somewhat modified, however, to explain the phenomena of intermittent fever. The fundamental principle to be established is, that irritation can ad- [intermittent ffver.] 101 mit of total disappearance for a longer or shorter period, and then return at stated intervals with its previous intensity, leading, finally, to change and alteration of the tissues of organs. It is contended that periodicity- is natural to a state of health; that the activity and consequent func- tional energy of many of the organs are not constant, but roused at certain periods, and during the intervals are in a state of comparative repose: thus the brain has its waking and sleeping hours; the stomach digests its food, and becomes quiescent; even the heart and lungs undergo diminution of energy. But there are more marked periodi- cal occurrences, as the menses, hemorrhoidal fluxes, &c, which give the idea both force and plausibility. On referring to the modification of irritation, by the tissue in which it is located, it will be found, that in those which are so anatomically constructed that it can easily be produced, and as rapidly removed, periodical irritations are universally seated. Such tissues possess a looseness of structure, and are rich in nervous filaments, and nutritive sanguine vessels. Those which are low in the scale of vital activity, which are closely allied to the osse- ous structure, and which, when once diseased, go through long and protracted changes, are not affected by periodical irritation. The tissues then in which this form of deranged organic action is mani- fested, are those which possess the highest degree of vital activity, as the brain, mucous membranes, and the hollow viscera. For reasons analagous to those which induced Broussais, to locate the primary irri- tation of continued fever in the stomach and intestines, he is led to maintain that the primary seat of intermittent fever, is in the same viscera; and without searching for the cause of periodicity, is satisfied of its existence as a fact. Intermittent fever, therefore, is regarded by him as a gastro-enteritis running through its stages in a limited time, and terminating by a translation of irritation to the skin, inducing profuse perspiration; and this constitutes a true crisis. The phe- nomena of the paroxysm, are accounted for in the same manner as those of fever generally, some of the preliminary symptoms being referrible to the organ primarily affected, the others to sympathetic disturbances. In proportion as the first is intensely affected, will the symptoms be acute, and the sympathies called into action, giving rise to attacks of greater or less violence. If any one of the vital organs be so much deranged, as to threaten life, as for instance the brain or lungs, a form of disease is assumed which is termed pernicious intermittent; or if attended with putrid or adynamic symptoms, it is called malignant intermittent. Intercurrent intermittents and remittents are only shades of the same disease, the irritation subsiding at intervals but 102 [intermittent fever.] not totally disappearing, and then again becoming kindled up with fresh energy, changing the type of the fever, but not its essential character. Congestion in important internal organs is the most for- m idable attendant upon these intermittent irritations; the blood is so forcibly, and in such quantity determined to them as to suspend their functions, or even to destroy them, in debilitated persons, or in those who are prone to irritation: this eflect is what is designated by the "lost balance of the circulation," and means nothing more than diminution of excitement, and anaemia of external organs, while a most irresistible attraction of fluid exists in the central. The analogy between continued and intermittent fever, the latter being regarded as identical in nature with the preceding, only running its course in a shorter time, is strikingly demonstrated, by the easy transition of one into the other. Thus by stimulating a patient labouring under the aggravated symptoms of intermittent, the periodical irritation can be converted into continued; and frequently the continued form may, by soothing measures, be made to evince a degree of, if not complete, periodicity. The irritation being disturbed, the transfer to the skin or crisis will be imperfect, which is another reason for the prolonging of irritation, and change to the continued form. Hemorrhagic and neuralgic irritations sometimes assume an intermittent character, hence the close affinity noticed by authors, between them and inter- mittent fever. M. Broussais endeavours to confirm his reasons for establishing the primum mobile in the stomach and bowels, by reference to the different organic lesions, which are found to ensue from protracted attacks, as chronic inflammations of the mucous coat of the stomach, with thickening and alteration of texture, enlargement of the liver, with alteration of function leading to jaundice, disor- dered digestion, and its concomitant evils; and enormous increase of the size of the spleen vulgarly denominated ague cake, these are all the results of that form of irritation constituting inflammation. M. Roche has thrown out some ingenious reflections upon the dis- ease which at present occupies us. He contends that fevers cannot assume the intermittent type unless the causes are of the same period- ical character; and upon an examination of them, it will be perceived that they are intermittent in duration. In the spring and autumn in- termittents most generally abound. Now it will be acknowledged that, during these seasons there is the most marked difference between the temperature of the day and night, and consequently at short intervals of a few hours, an alternation of action and reaction takes place in the human frame, which soon may be converted into habit. [intermittent fever.] 103 The impression of marshy exhalations is precluded during the day, in consequence of their being diffused and dispersed into the upper atmos- phere by the effect of solar heat, but as soon as the effect of this is re- moved,the upper strata are condensed and precipitated in aconcentrated form, so as to have acquired peculiar violence, when, coming in contact with the skin and mucous membranes, they are absorbed and produce the phenomena which constitute an accession of intermittent fever. If the action of marsh miasmata be intermittent, it is not astonishing that the malady which is produced by them is equally so. According to this author, the accession of the paroxysms is repeated by virtue of a tendency of our organs to reproduce certain acts which once had taken place, even when the cause first provoking them had ceased to operate. Very frequently the repetition of a paroxysm does not occur, in conse- quence of a withdrawal of the causes; this is proved by the fact that, removal from an infected district cures the disease in numerous in- stances. M. Brachet has paid some attention to the phenomena of intermit- tents. Basing his theory upon the peculiar views which he takes of the offices and connexions of the two nervous systems, the cerebro- spinal and ganglionic, he attributes the primary lesion to their de- rangement, to the exclusion of irritation as understood by the physio- logical school. The ganglionic system presides over all the actions of organic life, as nutrition, secretion, &c. while the nervous system of re- lation has charge of the connexion with the exterior world. Accord- ing to him, the phenomena of intermittent fever, are such as can only be produced by derangement of the healthful influence of the first, communicated to the second; and no matter whether the modifying impression is made externally by atmospheric or physical agents, or takes place internally by marsh miasm; the first effect is produced on the nerves of the organic movements. That the result of this impression is not inflammation, he proves by the following experi- ments. Towards the end of October, 1822, he took for seven nights in succession, at midnight, a cold bath in the river Saune. The first bath was of a quarter of an hour's continuance; the second half an hour; from this he went on protracting the time, until he was enabled to re- main in the water a whole hour. After each bath, he laid down in a warm bed and underwent considerable reaction, with increased warmth, followed by profuse sweating; after which he went to sleep. At the expiration of seven days, M. Brachet omitted his experiments, but was surprised to find, during the following day, thft between twelve and one o'clock, P. M. all the attendants of a true intermittent I 104 [intermittent fever.] paroxysm made their appearance. As he experienced no inconvenience during the interval, he allowed this artificial fever to proceed, and experienced six distinct attacks. Upon the seventh night following the last bath, he was called upon to ride some distance upon professional business, a short time prior to the expected invasion; the exercise thus taken produced excitement of his system, which Avas kept up by placing himself near a large fire, and from that time no accession re- appeared. This account corroborates, in a measure, the statement of M. Roche that intermittence of cause will produce a habit, more or less difficult to counteract, in proportion to the fixedness of it In speak- ing of these conclusions of M. Brachet, it is understood, that the paroxysm is simple in character, unaffected by organic lesions, which will modify its type and be productive of such complications as are found in these fevers of serious grade. Malignant intermittents assume forms which are characterized by acute symptoms, arising from serious lesion of some particular organ. If it be the brain, there will exist phrenitis, apoplexy, &c. If the heart, all the manifestations of cardiac invasion; if the liver, hepatic derangement; if the lower bowels, dysentery may be the complicating attendant The danger of these different complications, is measured by the importance of the organ and the force of the attack.] Treatment of Intermittents. It was formerly a matter of high dispute among physicians, whether an intermittent fever ought to be immediately cured, or allowed to run its course. Many believed that the system is benefitted by the disease,—that the febrile symptoms, in fact, are the natural cure of some other disorder in the constitution,—and they argue that curing it must be hurtful. Some still assert that the disease will cure itself; and therefore, that it is improper to apply any remedies, except laxa- tives, to keep the bowels open. The best maxim in physic is, to get rid of diseased action as quick- ly as possible; there is no saying what mischief is to follow in the train of consequences. "There could not be a moment's hesitation," says Dr. Fordyce, "in determining to restore the patient to perfect health at once, were there any remedy or mode of treatment that would certainly prevent the returns of the paroxysms of a tertain intermittent, and take off the symptoms remaining after the crisis, so that no other disease should follow. But there most undoubtedly is no medicine uniformly efficacious, or that always leaves the patient in INTERMITTENT FEVER. 105 tolerable health, and secure of not being destroyed by the remains of the disease, or by any other disorder arising in consequence of it."— Were there any such, why should different practitioners attach them- selves to particular varieties of bark; recommending the brown, the yellow, or the red, with such decided preference? Why should they prefer arsenic or zinc, if any one were uniformly successful? The discovery of such a remedy has always been a great desidera- tum; and although no one remedy has yet been found out, I believe bleeding, in the cold stage, conjoined with the occasional use of the sulphate of quinine, and laxatives, to be as certain a mode of treating intermittents, as any other set of remedies can be said to be certain in the treatment of any other class of diseases. Treatment in the Cold Stage.—As the cold stage demands differ- ent management from the hot, and both of these from the sweating stage, and all these from the intervals between the paroxysms, I shall treat of the means to be used in each stage, and then describe the plan which ought to be adopted in the intervals, to prevent a return of the complaint In the cold stage, which generally lasts from half an hour to two or three hours, the first thing to be done is to endeavour, by every means in our power, to restore the heat of the body, and to re- lieve uneasy feelings, with a view to shorten its duration, and bring about re-action. Hot applications; additional bed clothes: warm drinks; stimulants; opiates and aether, have been strongly recommended,— with how little success, every experienced man can testify. The best method of applying heat is, to surround the patient with bottles filled with hot water; and it affords considerable relief when a sufficient de- gree of heat can be applied to the epigastric region. It appears to be more efficacious than the general warm bath, in which I have seen a patient shiver, and complain loudly of cold, when the bath was heated above 100°. It is a common plan to give a bumper of gin or brandy, with some pepper, to create reaction, and cut short the cold stage; and there can be no doubt that it has sometimes succeeded; but I have seen much injury ensue in many cases. This enables us to account for the horror entertained by the older writers, at cutting short the cold fit, because it was never attempted by any other means than by ardent spirits, large doses of opium, and aether. Dr. Gregory used to mention, in his lectures, two cases of violent epistaxis, succeeding to doses of brandy and pepper, which reduced the patients to great weakness. In the instances which fell under my own observation, and to which I have already alluded, fever and violent cerebral symptoms succeeded, and, in two or three instances, local inflammations. Vol. I.—14 106 INTERMITTENT FEVER. Bleeding in the cold stage, will, in a great majority of instances, cut it short; in fact, it will rarely fail in stopping the existing paroxysm, and on many occasions it has prevented a return of the disease, to which the patients had been long subject, and by which they were nearly worn out. It is difficult to determine what quantity of blood it will be necessary to draw in any given case; sometimes it requires twenty four ounces; I have known three ounces suffice, and, in one case, an ounce and a half produced the full effect The larger the ori- fice in the vein is made, the greater is the chance of arresting the dis- ease at a small expense of blood; but, in many cases, the operation is attended with considerable difficulty, from the convulsive tremors which affect the whole body. I was once successful in arresting the disease by bleeding, in a cold stage which had continued twenty-six hours; but I regard this as an extreme case. The blood sometimes only trickles down the arm, and, as the system is relieved, the stream becomes larger and stronger, till at last it springs from the orifice, and frequently before six ounces are taken, the patient will express relief from violent pain in the head and loins, and it will soon be observed that he breathes more freely. The tremors become slighter and slighter, and, by the time a few more ounces are abstracted, they will cease altogether, and with them will vanish the painful sensation of cold. The pulse will be found stronger, and a gentle moisture will be ob- served on the body. If the patient be properly managed with respect to bed-clofties, neither hot nor sweating stage will in general follow. Most of the patients who have been treated by myself, or by my pu- pils under my immediate inspection, have fallen asleep immediately after the operation; but some have even got up and dressed themselves. The best testimony which can be offered in favour of bleeding in the cold stage of intermittents, is to annex a condensed history of some of the cases treated by myself and others in this country. Indeed, I have been blamed by many for not having done so in the first edition, but time has enabled me to perform this duty with more confidence, for 1 have now the satisfaction of adding an account of the happy re- sults of the practice in India. " Case I.—James Ward—admitted into Royal Ordnance Hospital in November 1823. Has had several attacks of intermittent annually, since the year 1809, when he served in the expedition to Walcheren. Of late his indispositions were long, and left him more and more de- bilitated. He was bled twice in the hot fit, to relieve the severity of the symptoms, and with considerable temporary relief, but without INTERMITTENT FEVER. 107 preventing or mitigating the violence of the subsequent paroxysms. He was afterwards bled from a vein in the arm, during a very severe cold stage; the rigors were violent, and the sense of cold insupportable. He complained much of his head and loins, the face was of a livid colour, and the vessels of the conjunctiva turgid with blood. Pulse 100 or 105, and oppressed; breathing short and anxious, and to use his own expression, he felt ' a heavy load about his heart' When the vein was opened, the blood trickled slowly from the wound, but it soon came in a jet When 8 ounces were taken, the rigors ceased, and he expressed great surprise at the suddenness of the relief; when 12 ounces were abstracted, he was free from all complaint, and his skin had a comfortable moist feel. He enjoyed a good night; he had no return of the intermittent; and his recovery was rapid. " I had an opportunity of seeing this man daily for some months afterwards, and his constant tale was, that he ' had not felt so well, or so much of a man,' since he went to Walcheren. The only reme- dies used after the bleeding, were laxatives and infusion of quassia." " Case II.—James Atkinson, aged 33, had formerly had repeated attacks of ague. Was seized with severe rigors when on the top of the Carlisle mail, travelling to Edinburgh. The paroxysm was evi- dently produced by exposure in bad weather, first to rain, and then to a keen frost, with wet clothes. When I visited him in hospital, he had labored under the rigors for no less a period than twenty-six hours,—in truth, it was the most severe cold stage I had ever seen in any country, with severe pain in the head, back, and loins; oppression atpraecordia. Warm drinks, stimulants, and hot applications, had been employed without benefit. The agitation of his body was so great, that it shook the very bedstead on which he lay, and threatened to terminate in con- vulsions. Tongue loaded, but moist; breathing hurried and laborious; pulse 65, oppressed; skin not below the natural standard over the trunk, but all his extremities were cold, and he complained of a sen- sation of extreme coldness. Fortunately, I made a good orifice, and the blood flowed in a good stream; the first pound was abstracted in three minutes, with very trifling relief, except to his breathing; but during the flow of the second pound, which occupied three minutes, he became more and more easy, and the rigor ceased completely. His body, and even the extremities, became of a proper temperature, and his skin felt moist; the pulse rose from 65 to 106; he passed a good night; had several stools during the next twenty-four hours, and was found perfectly easy next day. On the following day he was conva- 108 INTERMITTENT FEVER. lescent, looked well, asked for more food, and had no return of the disease." "Case III.—Thomas Bullock,a strong healthy young man, reports that he had the disease in the tertian form for twelve days. Attri- butes it to exposure to cold when on sentry in the arsenal at Woolwich. He was in the sweating stage when brought into the hospital at Leith Fort, on the 4th March 1826. " On the 6th had another paroxysm. " Sth.—Cold fit came on at three A. M. After it had continued half an hour and was well formed, his pulse beating 84 and oppressed, a vein was opened in the arm by Mr. Marshall, (now assistant surgeon of the 87th regiment) in the presence of several other gentlemen. When 15 ounces of blood were abstracted, the rigor ceased; the pain of head and loins, and the oppression at prsecordia, vanished; the breathing became natural; the pulse rose to 95. In half an hour after the operation, said he felt quite well; no hot fit followed; a very gen- tle moisture appeared on the surface,but there was no sweating stage; pulse 95. " 18th.—Was again attacked with rigors a quarter of an hour before the visit. He is now in a severe well-formed cold fit; breathing hur- ried and laborious; the whole body is in a tremor; tongue rather loaded; passed a bad night; pulse 120, oppressed. Attributes this paroxysm to cold when in the privy. A vein was opened in the arm, and 14 ounces of blood were abstracted before the fit was subdued; there was no tendency to syncope; pulse 110, full, and of good strength. No hot stage; no sweating stage followed. " 19th.—Yesterday, for some time after the bleeding, he appeared free from all complaint; but towards evening was attacked with vio- lent headache and pain in the belly. Blood was again taken from the same orifice, to the amount of 12 ounces, with complete relief, since which he has been easy and slept well; bowels slow. "20th.—Slight chill this morning, which appeared to be cut short bya warm drink; no fever followed; passed a good night; bowels not moved. " 22d.—Had a slight sensation of cold this morning, but there was no hot stage; says he feels quite well; bowels slow. " 23d, 24th, and 25th.—Reports state that he went on improving. " 26th.—Says he does not feel so well; but there has been no ten- dency to rigor; bowels bound. " 31st—He went on improving in health, and without any return of the disease till this day. He was found at the time of the visit in INTERMITTENT FEVER. 109 a slight hot stage, after having experienced a slight rigor, which lasted for twenty minutes; tongue white and loaded. " April 2d.—Had a severe rigor at 10 A. M. which was followed by fever and sweating; at 2 P. M. he was found quite free from com- plaint. " His health went on improving gradually till the 25th, when he was discharged the hospital, cured. " The same individual reported himself sick on 30th May following, and was taken into hospital, after a severe paroxysm of intermittent. On his admission he stated, that since his discharge, his health had been very good, and his strength increasing, but that he has had three slight rigors; his appearance, however is much improved. " 31st—Says he expects the paroxysm to-morrow morning at nine o'clock; bowels regular; appetite good. " Was ordered to take three grains of sulphate of quinine every half hour, commencing three hours before the expected time of attack. " June 1st.—He took six doses of the quinine; escaped the pa- roxysm; had no return afterwards, and was discharged on the 4th." " Case IV.—Robert Smith, a stout man, whose health had formerly suffered from a residence in a warm climate, states, that he had had an intermittent fever five years ago when stationed at Woolwich, but has not had areturn of the disease till now. Was taken into hospital at Leith Fort, on 7th March J826, laboring under febrile action, which he said succeeded to a severe rigor; the febrile symptoms continued, with dis- turbed sleep, till the 13th day, with little variation. He was then seized with a severe rigor, attended with sensations more than usually distressing; above all, he complained acutely of his head. He was bled during the cold stage to twelve ounces, when the tremors and the other symptoms ceased all at once; he soon after fell into a profound sleep, his skin having a gentle moisture; there was no hot stage. " Escaped an attack till the 22d, when he had a severe paroxysm, followed by intense headache, for which he had leeches, cold applica- tions, and a blister. He afterwards took sulph. quininae." "Case V.—William Macauley was admitted into the Royal Ord- nance Hospital on Wednesday 31st May, labouring under a severe hot fit, attended with the usual symptoms. " June 4th.—The paroxysm took place at 1 o'clock P. M. this day; about 12 o'clock the pulse was counted, and was found to beat 84, and oppressed; the precursory syjnptoms had just commenced; at 110 INTERMITTENT FEVER. half past 12 the pulse was 66, and still more oppressed. This rigor was very severe; the tremors of his body shook the bed, and his sense of cold was insupportable, at the time that a thermometer placed under the tongue stood at 100. He complained of great oppression; pain of back and loins; difficult and hurried respiration. The rigor was al- lowed to be formed for 10 or 12 minutes before a vein was opened, 24 ounces of blood were then drawn, the rigor ceased, and all its un- pleasant symptoms. " He had about eight slight paroxysms after this, and was subse- quently cured by the use of quinine." " Case VI.—Alexander Clark, a stout well-made young man with a florid complexion. " Came into hospital at Leith Fort on 26th May 1826, with the fourth paroxysm upon him. He was attacked at 7 A. M. with rigors; the fit was very severe. The hot stage had given way to the sweating when 1 saw him. He could assign no cause, except that he had done duty at Woolwich a few months before. Tongue foul: fever diet. "23d.—Was free from complaint yesterday; had six stools from the laxative. The rigor came on this morning at half past six, and went through the regular stages with the usual distressing symptoms. Tongue much loaded; B. regular; no appetite; urine scanty. " Experienced severe paroxysms on the 24th and 26th, attended with headache and a severe pain in right hypochondrium. " 28th.—Rigor came on at 11 a. m. Five minutes after it was well formed, a vein was opened, but the operation was badly performed, owing to the violent tremors; 20 ounces of blood were slowly drawn, when the rigor ceased, together with tremors, the difficulty of breath- ing, the oppression at praecordia, and the headache, &c. The painful sense of cold gave way all at once to a pleasant feeling of heat, and the pulse became natural. The bleeding was not carried the length of producing syncope. No hot stage followed, and the skin was cov- ered with a gentle moisture. In half an hour his only complaint was of slight nausea. " He had several slight returns of the disease, and ultimately re- covered under the use of quinine." " Case VII.—Mr. Marshall, assistant surgeon of the 87th Regiment, when on a visit in the west of Scotland, was called to see a middle aged man who had served in the army in a warm climate, and who had suffered most severely for some years from intermittent fever. INTERMITTENT FEVER. Ill Every kind of remedy had been tried in vain, and he gladly submit- ted to the treatment of bleeding in the cold stage, which Mr. Marshall had seen so successfully performed in similar cases. ' 12th.—The cold fit is very severe; the feet cold; heat of the superior extremities rather above the natural standard and moist; pulse very small, not easily perceived; pain of head excessive; great'thirst; pain in back considerable; complains of distressing sense of weight at the praecor- dia. A vein was opened, and the blood trickled down the arm, but shortly came in a full stream. When ten ounces of blood had flowed the shivering ceased, and all the bad symptoms vanished. Half an hour after the bleeding, says he is quite well. On the 14th, 16th, 18th, no return of fever.' Mr. Marshall assured me that he had no return of the complaint when he last visited him, which was several months after the bleeding, and that the cure seemed to be as sudden, and ap- parently as permanent, as that which took place in Ward's case." "Case VIII.—George Scott, aged 36, a native of Eyemouth, was seized with an intermittent of the quartan type when in Lincolnshire in August last. He had used various remedies, and among the rest bark, without relief. The paroxysms have continued with such re- gularity, that he has not escaped a single attack since the commence- ment of the disease. His health and strength have suffered so much, that he has been unable to work for a considerable time, and came to Edinburgh almost in despair, to seek relief. His look is meagre and emaciated; and he appears the wreck of a strong and active man. "On Thursday 2.sth December 1826, at 2 p. m. the rigor commen- ced, and when it had continued for half an hour, I opened a vein in the arm, having placed him in the sitting posture; his whole body was affected by violent tremors; his teeth chattered; he complained of in- tense cold; dimness of sight; severe pain in the back part of the head, and in the left side, loins, and inferior extremities; his pulse was quick and fluttering, so as not to be counted, and the countenance expressed great suffering. Owing to the violence of the tremors, a bad orifice was made in the vein, and the blood flowed slowly. When about twelve ounces were abstracted, the rigors diminished, the uneasy feel- ings began to subside; and by the time 16 ounces were taken, he was free from tremor and pain, and said he felt quite well. The pulse was now a good pulse, but I neglected to make a memorandum of its num- ber at the time. He showed some tendency to syncope before the arm was tied up. Several gentlemen were present when the opera- tion was performed. He was again visited in an hour, when he was 112 INTERMITTENT FEVER. found breathing naturally, in a sweet sleep. Pulse 84, and of good strength. I was told he had been very faint, and had vomited imme- diately after we had left the house. " Saturday 30th.—He came to the dispensary at the visiting hour, and said that he felt himself 'a new man.' "Sunday 31st.—He came to the dispensary again, and was there seized with a paroxysm a little after the hour of visit. The fit was pre- ceded and accompanied by much slighter pains and general disturb- ance than any former attack. In about ten minutes after the fit could be said to be well formed, the rigors were very severe, the tremors violent, and the feeling of debility was so overpowering that he de- clared he could not support himself longer on a chair; his breathing was quick and laborious, and his teeth chattered; I tied up his arm and opened a vein, and before three ounces were abstracted, the pa- roxysm ceased, and with it all the other unpleasant symptoms. Al- though a minute before he had declared that he could not sit up a mo- ment longer from debility, yet he now said he felt his strength re- stored, and had no wish to lie down; in less than ten minutes, I had the pleasure of seeing him running home. There was no subsequent heat of skin, and no sweating; his pulse, before he left the dispensary, was 86, and of good strength; whereas before the bleeding, it was 100, and so weak as scarcely to be counted. " Monday; 1st January.—I sent to inquire how my patient felt; the messenger was told that he had had a good night, and was out making merry with some friends. " On Wednesday he had a slight chill without subsequent fever or sweating; he afterwards got the sulphate of quinine, and had no more of the disease." " Case XVIII.—The following is the case of James Bennett, treated by Dr. Alison in the clinical ward of the Royal Infirmary, which was the foundation of his lecture against bleeding in the cold stage, and whose objections and arguments were subsequently re-echoed in the Lancet of Saturday, April 7, 1827, in a communication signed ' Scotus.' "James Bennet, aged 39, shoemaker, March 27th.—Had severe rigors on Saturday 25th instant, accompanied by thirst, anorexia, and pain of the head, which continued for more than an hour; were then succeeded by heat of the skin, vertigo, lassitude, increase of thirst, and pain of the head. These symptoms continued five or six hours, and then gradually subsided during copious sweating. Had a INTERMITTENT FEVER. 113 similar paroxysm on the 26th, and also a less severe one this morning. Complains at present of a slight pain below the left false ribs, some- what increased by pressure or coughing. Pulse 60, full. Respiration natural. Skin cool. Tongue clean and moist No thirst. Appetite pretty good. Bowels open. Urine said to be high coloured. Lips somewhat swollen, with a slight vesicular eruption around the mouth. Has taken purgative medicines, and also a little of the arsenical solu- tion since yesterday. Took an opiate draught this morning when the rigors commenced, after which they continued only a few minutes. Has since had no pain of head; little heat of the skin; less thirst, and sweating. Had the intermittent fever more or less constantly for nine months, whilst in Spain, fourteen years ago. Has recently re- turned from the West Indies where he resided for the last six years. Lives in a house where several persons have been ill of continued fever.—Fowler's arsenical solution, gi. Water, 3 vi. Mix. Let him have 3ss every sixth hour. "2Sth,—Shivering commenced this morning at ten, which abated somewhat after taking the draught. At half past ten was still shiver- ing, less violently; with pain of back and head. Pulse 72, rather small. Sixteen ounces of blood were taken, slightly sizy, crassamen- tum not contracted. The pains abated and the shivcrings immedi- ately ceased. Has headache now, and giddiness. Pulse 72, full, soft, tongue furred, moist. No sweating since the shivering. Pain of left side of abdomen only felt on coughing, No pain of back.—Continue the arsenical solution.—Repeat the anodyne draught. " 29th.—Began to sweat at two, which lasted several hours. Had griping and tenesmus with headache at night, which abated after the operation of a dose of castor oil. No shivering to-day. Four doses of the solution taken. Pulse 60. Tongue moist, slightly furred. Complains of weakness.—Continue all the medicines. Let him have lb. i. of beef tea, and one pint of porter. "30th.—Had a fit of^rigors this morning about ten, and took his draught. The shivering was less violent, but lasted an hour. Pulse 80, full, soft. Heat was an hour ago 100°. Tongue slightly furred, with thirst: Complains of headache, pain of back and left side of abdo- men. Bowels confined. Let him have one oz. of castor oil: a saline draught now and then. Continue the others. .. 31st.—Much sweating yesterday after having had an enema at night without eflect. No rigors to-day. Pulse 6S. Tongue whitish. __Let him have gij. of effusion. Senna, with jij. of sulphate of mag- nesia.—Repeat the arsenical solution now every fourth hour. Vol. 1.—15 114 INTERMITTENT FEVER. "April 1st—Bowels freely opened. Rigors commenced to-day at ten, but slightly. They have become more violent within these few minutes. Pulse 84, pretty full. Skin feels warm. Tongue rather dry. Has pain of left side of abdomen just now. Has just taken the anodyne draught.—Continue the arsenical solutiom Give him a powder containing four grains of sulphate of quinine every six hours. " 2d.—Shivering abated quickly after the opiate draught. Sweated much in the evening. Feels easy to-day. Left side of the abdomen slightly tender. Bowels open. No nausea.—Repeat the powders of sulphate of quinine every fourth hour. "3d.—Four powders taken. No fit. Very little pain of side.— Continue the medicines. "4th.—Five powders taken. No fit. Two stools. Appetite good —To have four ounces of steak to-day, and daily. "5th.—Had a very slight fit of rigors at four yesterday, succeeded by heat of skin; full, quick pulse, and sweating in the night; little headache, and no pain of side. Pulse and tongue natural. Bowels open.—Continue. " 6th.—Shiverings have began* within these few minutes. Pulse 96. Has taken his draught. Hand rather cold. Bowels open.—Continue. "7th.—Shivering lasted an hour yesterday. Began to sweat soon after, and sweated all night Complains of pain in the left lumbar region, with some tenderness; no distinct hardness. "8th.—Rigors commenced this morning a little after 9 o'clock, and lasted an hour, though he took an opiate draught containing forty drops of tincture of opium. Has sweated some already. Pulse 100, full. Complains 'of headache and pain of left side of abdomen. Tongue rather dry, with some thirst. No stool.—Let him take a bolous of compound powder of jalap directly. Apply the cupping glasses to the pained part of the left side, and abstract six ounces of blood. Continue the powders of sulphate of quinine. Let him have drink, acidulated with lemon juice, without syrup, ad libitum. " 9th.—Side easier since the cupping. Bolus operated. No head- ache to day. Appetite good. Much sweating in the night.—Continue. Let him take a mixture containing 3i. of sulphuric acid with water. —Additional bread. "16th.—Had some vomiting this morning, succeeded by rigors about 8 o'clock which lasted three quarters of an hour, but were not violent. Pulse 64. Heat 99°. Sweated a little. No headache or pain of side. Bowels slow.—Let him take 51J. of infusion of senna with 5ii. of sulphate of magnesia, directly. Continue the others. INTERMITTENT FEVER. us " 17th.—Had a second fit of rigors yesterday at 2 o'clock, which lasted long, although he took forty drops of tincture of opium. Sweated all night. Is free from complaint to-day, but weak. Bowels open. —Continue the powders of sulphate of quinine every third hour. " 18th.—No return of shivering. Has a little pain of left side of abdomen, on motion or coughing. Pulse natural. Appetite good. One scanty stool.—Give him directly a powder containing gr. xv. of rubarb, and gr. iii. of calomel. " 27th.—Complains of feeling weakness of loins.—Apply a warm plaster to the lumbar region. "29.—Bowels slow, otherwise well.—Let him have immediately a cathartic draught. Continue the others. " 30th.—Has complained of nausea and weakness, but without any shivering. Pulse natural. Tongue whitish.—Let him take gi. of a mixture containing ^ij. of ammoniated tincture of valerian, in 3vi. of mint-water. Continue the others. " May 1st.—Feeling of nausea and headache abated. Bowels regu- lar.—Let him have one ounce of bark, also a warm plaster for the loins. Dismissed cured." Second attack.—" Admitted 25th May.—On the morning of 17th instant, was taken ill with headache, languor, and pain of back, suc- ceeded by slight rigor, which continued for about a quarter of an hour, when it was followed by heat and sweating. Has had an interval of seven days without a return of paroxysm, which re-appeared on the 24th with increased severity, the rigor having been much more violent, and of longer duration, accompanied with much nausea, excruciating headache, and those various symptoms which characterise the invasion of intermittent fever, under an aggravated form. Has had this morning, previous to admission, another paroxysm, which was an hour earlier in the period of its accession, and continued, including its three stages, for about six hours, during the first of which he had much vomiting. Complains most at present of headache, prostration of strength, general lassitude, and soreness of limbs. Has no pectoral or abdominal symp- toms; thirst is urgent; no anorexia; pulse 66, full, but soft; respira- tions 26 in the minute; tongue furred, but moist; bowels open; skin warm, rather pungent, and bathed in perspiration; face swollen; urine copious. Has been lately a patient in this clinical ward, afflicted with his present complaint, of which he was dismissed cured, on the 30th ultimo. The history of the present case derives much additional in- terest from the circumstance of two of his children having been also recently attacked with ague, for which one of them is now a patient 116 INTERMITTENT FEVER. in the infirmary.—Let him have gr iij. of sulphate of quinine three times a-day, and two colocynth pills to-night. " 26th.—Three stools from the pills. No shivering since admis- sion. Headache still severe. Pulse 66, full. Pain of back and limbs, preventing sleep. No pain of side or of abdomen.—Apply the cup- ping instrument to his temples, and abstract eight ounces of blood.— Continue the powders. " 27th.—Headache relieved by cupping. Had a severe shivering fit this morning, reported to have lasted two hours, and is now sweat- ing profusely. Pulse 66, full. No pain of abdomen or side. Two stools.—Let him have the powders of sulphate of quinine every third hour. Also an anodyne draught, with forty drops of tincture of opium, at the commencement of the paroxysm. " 28th.—Pulse 66. Feels chilly. Bowels open.—Continue pow- ders of sulphate of quinine. " 29th.—Had a shivering fit lasting an hour and a half, commence- ing at nine. Has sweated much. Pulse 66, full. Complains of general soreness. Bowels open. Had nausea, no vomiting.—Let him have an effervescing saline draught every hour.—Continue the powders. " 30.—Pulse natural. No pain to day. Appetite pretty good. Five powders taken.—To have four ounces of steak and a pint of porter. " 31st.—Took six grains of sulphate of quinine this morning at half past eight. Shivering came on at nine, and lasted about half an hour, but was much slighter. No sweating since. No headache, but complains of nausea and giddiness. Bowels open.—Let him have the effervescing saline draught now and then. Continue the powders. To have ordinary diet to-day, but the steak to be repeated to-morrow. "June 2d.—Took a double dose of quinine again this morning at half past eight Has had a little chilliness; no rigor.—Continue the powders. " 3d.—Began to shiver directly after visit yesterday. Took five grains of sulphate of quinine, after which it went off. Sweated much. Has complained much of tinnitus aurium and giddiness since yester- day afternoon. Two stools from pills taken last night. Pulse 6S, full. Tongue whitish.—Repeat the powders every fourth hourj and the laxative pills at bed time. " 4th.—No shivering to day. Much less tinnitus. Bowels open.__ Continue the powders and pills. " 5th.—Five powders taken. No vertigo or tinnitus. Appetite good.—To have additional allowance of bread. " 6th.—Had chilliness; no rigors. Six powders taken. Bowels INTERMITTENT FEVER. 117 slow. No pain.—Let him take two colocynth pills immediately. Con- tinue the powders. " 7th.—No return of shivering. Complains only of pain of back.— Apply a warm plaster to the lumbar region. Continue the medicines. " 8th.—Bowels slow. Feels drowsy to day. No shivering.—Let him have the colocynth pills.—Continue powders. " 13th.—Bowels slow.—Let him take a cathartic draught. " 15th.—Two laxative pills at bed time. " 17th.—Inflammation of eyes, particularly of right, with adhesion of eye-lids in morning. No headache.—Let him have 3i. of compound powder of jalap immediately. To bathe his eyes frequently with tepid water, and to apply simple ointment to the edges of the eye-lids. " 18th.—More inflammation of right eye.—Apply the cupping in- strument to his temples. Repeat the powder of sulphate of quinine three times aday. " 20th.—Eyes still sore.—Apply eight leeches round the eyes. "21st—Two leeches only fixed. Bowels confined. Inflammation of eyes somewhat abated.—Repeat the leeches and purgative draught. " 22d.—Leeches bled well. Eyes less painful. Still inflamed, with discharge of tears.—Dissolve gr. xv. of the acetate of lead, in 5viij. of water, for a collyrium. "24th.—Both eyes somewhat inflamed, with impatience of light, and dimness of sight.—Abstract from the arm 5 x. of blood. Continue medicines. " 25th.—Eyes better. Bowels open.—Continue the lotion for the eyes. " 26th.—Still some pain of eye-balls; less inflammation, but has some dimness of sight. No pain of head. Iris moves well.—Discon- tinue the powders of the sulphate of quinine. Apply a blister to the nape of neck. " 30th.—Still some dimness of sight—Let him have 3 !• of simple ointment.—Dismissed cured. I have been favoured with the following case of coma, occurring in the cold stage, treated successfully by bleeding, by Dr. Henry Lucas of the Royal Artillery. " Case XXIV.—Gunner William Smith, 9th Battalion. Admitted, August 16, 1S27, is perfectly insensible; eyes fixed, pupil partially contractile; respiration slow and deep; pulse full and slow; skin cool, especially about the lower extremities. Is completely insensible to 118 INTERMITTENT FEVER. external stimuli. Was brought from one of the guard rooms, where he had been complaining of feeling ill. Had had attacks of ague. A vein was opened in the arm, and he recovered sense and motion on losing six ounces of blood. He complained of cold, though by that time the skin was warmer. Twelve ounces of blood were taken. Warm bottles were applied to the feet; cold lotion to the head; and a turpentine enema. In the evening he was found sweating. Bowels not free.—Cathartic mixture ordered. " 17th.—Bowels moved once by the mixture. Pulse soft and full. Skin moist and warm. Tongue rather loaded.—Repeat cathartic mixture. " 18th.—Had distinct rigors last night, succeeded by increased heat of surface and sweating. He was discharged on the 24th, cured. " Cases XXV. and XXVI.—The following is the extract of a letter from Mr. Brown, now assistant surgeon in the 52d regiment, dated Jersey, 8th August 1827 : "Since I had the pleasure of hearing you lecture, I have, in three instances, tried the eflect of bleeding in the cold stage of intermittents, and twice with complete success. The patients were invalids, sent from Gibraltar for change of climate. One had had ague for eighteen months previous to his coming under my care; and at the time he left the depot for Chatham, seven weeks from his being in hospital, he had no recurrence of fever. In the third case I was not so successful; it was, I think, from the bungling man- ner in which I opened the vein, I could not get the blood to flow." Cases XXVII. XXVIII. XXIX. and XXX. " Cork, Marlborough Street, Wednesday Nov. 14, 1S27. " Sir,—The perusal of your paper upon the utility of blood-letting in the cold stage of intermittent fevers, induced me to resort to that remedy, in the only four cases of the disease which I have met with since. The disease is of comparatively rare occurrence in this citv, and never assumes a very aggravated form. Three of the cases I allude to were stout laboring men; the fourth was a delicate girl about twelve years of age. None of them presented very dangerous symp- toms. The most distressing symptom was severe pain in the head, which was generally most intense during the cold fit The loss of blood, so far from causing collapse, or adding in any degree to the feeling of debility which existed, seemed to produce quite an opposite effect. The patients expressed themselves immediately relieved a gentle perspiration ensued, and they appeared as if revived by the in- INTERMITTENT FEVER. 119 fluence of a generous cordial. The bleeding, however, did not effect a cure; but the subsequent attacks were infinitely more mild, and yielded in a short time to the exhibition of the arseniate of potass. " The beneficial effects of this practice fully answered the expecta- tions which you announce; and I have no hesitation in saying, as far as I can judge from limited experience, that we are indebted to your sagacity for a bold and unusually successful innovation in the treat- ment of a disease which has constantly baffled our best directed efforts. You will excuse this brief communication, but I am aware that no re- ward is more grateful to a physician, than the assurance that his sug- gestions have received and merited the approval of his brethren. I am, Sir, with much respect, your obedient servant, (Signed) D. B. BULLEN, M. D." To Dr. Mackintosh. " Sir,—In consequence of having read, with great interest, your valuable paper upon the subject of bleeding in the cold stage of inter- mittent fever, which was published in the Edinburgh Medical and Surgical Journal for April last, I resolved to adopt your plan of treat- ment, in the first case of ague which should occur to me. Ague has not for many years been endemic in this neighborhood, so that the opportunities I may have of further trials of your treatment will pro- bably not be numerous. The results of the two cases, of which I take the liberty of sending you an account, are very favorable. They oc- curred to me in my practice as physician to the General Infirmary ,|i here. With a strong conviction that future experience will confirm correctness of your views and practice, and with feelings of admira- tion and esteem for an individual, who has improved the practice of medicine, by a disregard to long established prejudices, and erroneous doctrines, I remain, Sir, your obedient servant, JONAS MALDEN, M. D. Worcester, July 27, 1827. To Dr. Mackintosh, Edinburgh." " Case XXXI.—May 5, 1827.—Priscilla Williams, aet 30. Com- plains of pain in the head. Skin hot. Tongue furred. Pulse 120, small and rather hard. Pain in the epigastric region, with loss of ap- petite. Bowels confined. Has a severe rigor every other morning of half an hour's continuance, which is followed by a hot and sweat- ing stage. Her complaints began with cold shivering, three weeks ago, in the neighborhood of Oxford, where ague was prevailing.—Ap- 120 INTERMITTENT FEVER. plicentur hirudines xii. regioni epigastricae. R. Extracti colocynth. co. gr. xv. Hydrag. submuriatis gr. iii. Fiant pilulae tres stat su- mendae. R. Liq. antimon. tart. n\,. xx. Potassae nitratis gr. x. Mist Salinae 3 i. m. Sumat quartis horis. « 6th.—Pain in the stomach relieved. Headache continues. Bowels freely opened. No rigor yesterday.—Let her be bled during the cold stage to-day. a 7^—Lost ten ounces of blood yesterday during the rigor, when she became rather faint. A hot and sweating stage succeeded. Bowels open. Tongue cleaner. "8th.—Pulse 80, and of moderate strength. Headache and pain in the stomach much better. The rigor came on this morning, during which she was bled to 16 ounces, and a slight hot and sweating stage succeeded. " 9th.—Another very short and slight rigor this morning. " 10th.—Ague returned to-day, but bleeding cut short the cold stage, which was neither followed by heat nor sweating. "13th.—Pulse 72. Tongue cleaner. Appetite good. Free from pain. Has had no ague since last report Wishes to leave the hospi- tal. Discharged. " 27th.—I saw the husband of this woman, who told me his wife was quite well, and had no return of her disorder. " Case XXXII.—May 22, 1827. William Holland, aet 24. Has pain in the head and limbs, with furred and dry tongue. Pulse 96, small. Bowels regular. Has severe rigors of an hour's duration every day, which are followed by the hot and sweating stages. He has great prostration of strength, and a sallow countenance, and is much emaciated. Illness began with a shivering ten weeks ago. He has for some time been wandering about the country, and sleeping in the open air at night.—R. hydrarg. submuriatis gr. iv. Pulveris jalapa? gr. viii. M. f. bolus stat. sumend. "23d.—Had a rigor yesterday which lasted an hour, and was suc- ceeded by a hot stage and profuse sweating. The pulse in the rigor was 120, and very small. The bowels have been freely opened; stools of a good colour. Headache continues. Fiat venaesectio dum rigor adsit. "24th.—Was bled to fourteen ounces during the cold fit yesterday. Whilst the blood was flowing, the shivering diminished. The hot stage followed, but lasted much shorter time than usual. The pulse was not perceptibly affected by the bleeding. Sumat mistura cathar- tica 5 iss pro re nata. INTERMITTENT FEVER. rii " 25th. Is much improved in appearance. Pulse 80, soft The rigor came on at the accustomed time yesterday, but the shivering was less violent. Venesection was repeated during the paroxysm. The blood flowed freely, and the rigor ceased immediately upon tying up the arm. The cold fit lasted twenty minutes. The pulse during the rigor was 120. No hot fit followed. " 26th. Had a slight tremor yesterday, which lasted an hour. The hot stage afterwards scarcely perceptible. Bowels open. Tongue much improved. Pulse natural.—R. Sulphatis quininae gr. ii. infusi rosae § i- m. Sumat secunda quaque hora. " 27th. Had a short and slight shivering yesterday afternoon. No hot stage. Another at two o'clock, a. m. "29th. No return of the ague since last report. Pulse 72. Bowels regular. Tongue clean. He makes no complaint. " June 2d. Continues well. From this time till the 14th he had no return of the complaint. He had regained flesh and a healthy ap- pearance, and was discharged cured." The practice of bleeding in the cold stage has also been successfully tried by Dr. Ilaviland, Professor of the practice of physic in the Uni- versity of Cambridge, the result of which was communicated to me, with Dr. Haviland's permission, by Dr. VV. IT. Yates. The following are extracts from Dr. Yates's letter: " Dr. Ilaviland tells me, that in consequence of your communication to the profession on the proprie- ty of bleeding in the cold stage of fever, he was disposed to make trial of it, having, as you would expect, frequent opportunities in these low countries. His principal object was in the first place to ascertain how far it was practicable; for when he read the account, it struck him that it was a practice quite consonant with his own views. He was always assured that in these cases there existed considerable congestion of the larger vessels, and that, could a portion of their contents be safe- ly removed, the general result would be good. He has since tried it in several cases with decidedly beneficial effects." A clinical report on the success of bleeding in the cold stage of in- termittents in India, was read by Mr. Twining at a meeting of the Medical Society at Calcutta, on 5th December, 1829. This report comprehends ten cases, all of which were successful. In a second communiction of Mr. Twining, read at a meeting of the Society at Calcutta, on the 1st of May, 1S30, additional cases were brought forward. Several very whimsical objections have been brought forward by Vol. I.—16 122 INTERMITTENT FEVER. Professor Alison, against venesection in the cold stage of intermit- tents. These were strongly and eloquently urged in a clinical lecture by the professor, upon the case of James Bennet, which will be found at page 112 of this work. Statements made in a lecture scarcely de- mand notice, but as they have been published in one of the Medical Journals, it has been deemed advisable to enumerate the objections here, in order to expose their weakness and fallacy. 1*/, It has been said, that although venesection in the cold stage does not actually produce death, as was formerly imagined, its immediate or ultimate effect must be debilitating. Even in a continued fever, when the disease is cut short by the bleeding, the effect is debilitating; but as in intermittent we may expect a number of paroxysms, the debility is still more to be dreaded in the progress of the disease. Now this is after all only a truism; but allowing that the effect would be productive of thrice the degree of debility, yet who would not joyfully compound to cure the fever at the first onset of the disease even at such an additional expense? The cases I have already published, which were narrowly watched by a multitude, I may say, of observers, proves that this kind of debility is purely hypothetical. Not only in fevers produced by sub-acute in- flammatory action of some important organ, but also in pure inflam- mations of the same parts, we bleed in order to produce debility, not as a matter of choice, but as choosing the least of two evils. But this term debility, is ever haunting the imagination of the Cullenians, ac- cording to whose erroneous system, not only are spasm, delirium, and the tremors, but also the oppression of the pulse, the disorder of res- piration, the want of appetite, the nausea, and the vomiting, which ac- company a paroxysm of intermittent, all ascribed to debility. It is no wonder, therefore, that from a priori reasoning, the disciples of this system should object to this practice under such erroneous patho- logical views. But they should recollect that I bleed only in certain cases of intermittent, not to produce debility, but to restore the balance of the circulation at as small an expense of blood as possible. 2d, It has also been said, that " bleeding in the cold stage has generally been condemned, and probably from experience." I beg most respectfully to ask the Professor, by whom has it been practised, and for what reasons condemned? 3d, It has been said that it cannot be successful, because " it at- tacks the effect, and not the cause, of the disease." Let me ask, who knows any thing of the cause of any disease which affects man- kind? There is a great deal of pedantry and ambiguity concerning INTERMITTENT FEVER. 123 this term cause, as it is generally used in medical language. In em- ploying it, some mean to express the agent, whether known or un- known, which actually induces the disease. For example, the appli- cation of boiling water to the surface of the body produces inflamma- tion and its consequences. This is a known cause. An imaginary substance, to which the name of marsh miasm has been applied, is an example of the second. It is this unknown substance to whose agency intermittent fever is ascribed. Another sense in which the term cause has been applied is the first diseased action induced by either of the agents. It can easrfy be shown how very absurd this objection really is, taking it in either sense. In the case of the scald we are called upon to treat the effect and not the cause;—the hot water is removed, but the effect remains. A. B. has intermittent fever; the cold stage is long and severe; the constitution is too much oppressed, and the patient dies; or rather let me suppose, he would have died but that he is bled. Is it not absurd to object to the practice, merely because the practioner is not " mea- suring swords" with the cause, viz. the marsh miasm, but treating the effect? Or, A. B. has had the cold fit, and is now laboring under high excitement, and the powers of the constitution are unable to produce the sweating; inflammation in the head, chest, or abdomen, takes place; or it may prove to be a continued, remittent, or bilious remit- tent fever; are we not to treat the case pathologically, because we should only be attacking the effect, and not the cause of the disease? In the other sense it will be seen to be an equally erroneous objec- tion, viz. the first diseased action produced by any agent whatever. Let me ask who can point out the first link in the chain of morbid action? Is it in the nervous system, or in the vascular? Both are seriously involved. If in one, how is it communicated to the other? Who knows the structure of a nerve, and who is acquainted with its physiology? If in the vascular system, whether is the primary dis- eased action in the arteries or veins, in the capillaries or the trunks, or is the blood itself affected. It is wholesome to put these questions home to that medical man who is too nice in investigating the occult causes of diseases. If the practice pursued by medical men were to be rejected, and condemned as being "unsatisfactory and unscientific," (as venesection in the cold stage has been by Dr. Alison,) because they treated the effect and not the cause of the disease, I fear the profession of medicine would soon be at an end, and its professors left in a more miserable plight than Shakespeare's poor apothecary. Upon this principle, it is unsatisfac- 124 INTERMITTENT FEVER. tory and unscientific pathology which leads us to bleed, blister, and give purgatives for the cure of any disorder, because we are treating the effect, and not the cause of the disease. 4th. Another objection has been made, that bleeding in the cold stage is only, to say the very best of it," a palliative remedy" Does not a similar objection apply to bark and arsenic? " It may, how- ever, be remarked," (says Sir James Fellowes, at p. 382,) " that, in taking a review of the general practice in intermittent fever, the means usually adopted appear to have had no other view than to lessen the inconvenience of the paroxysms, and that thPy have not always been sufficiently active to put a stop to the disease in a way that was satisfactory to the patient or to the practitioner." To say the very worst of it, therefore, the practice does not stand on weaker ground than the other remedies. I have seen much mischief done by the use of bark in aguish districts; and I have known one man killed by arsenic. Clark (on Long Voyages) mentions a similar accident, but I have as yet known nothing but advantage to proceed from bleeding in the cold stage. I wish not to be understood to mean that bark and arsenic will always produce bad consequences, or that bleeding in the cold stage will invariably prove beneficial. I am convinced that both kinds of remedies require sound judgment in their application; and that if there is any organic engorgement or alteration of structure, bark must be injurious, if it has any effect at all, and that this is one of the cases likely to be benefited by bleeding in the cold stage. 5th. This practice has also been objected to, forsooth, because it is a " mechanical remedy." It is said " to affect the powers ivhich move the blood, but it cannot affect the altered state of the blood itself." That it does affect the powers which move the blood is a fact which cannot be denied, and this is precisely one of its great advan- tages. But to say "that it cannot affect the altered state of the blood," is a mere assertion. I maintain that it does also affect the altered state of the blood. Without entering into the physiological controversy about the nature of the changes which the blood undergoes during its circu- lation through the lungs, I may content myself with stating the fact, that some change necessary to life does take place on the blood in the lungs. From the commencement of the cold stage, the condition of the respiration decidedly proves that the functions of the lungs are much embarrassed. It is not even necessary to inquire into the cause of the pulmonary distress. They cannot perform their functions;__ does it not therefore follow that the blood cannot undergo the usual and necessary changes ? The blood is in a morbid condition, and INTERMITTENT FEVER. 125 when taken from a vein in very severe cases, it looks black and does not coagulate. Under such circumstances, when bleeding is had re- course to, it relieves the circulation, unloads the vessels of the lungs, and thereby enables them to perform their functions; the blood is acted upon, and the usual changes are effected. Therefore this " me- chanical remedy" does also affect the altered state of the blood. But there is another interpretation of the expression, "altered state of the blood." It may relate to a supposed alteration produced on the blood by the morbid agent, the marsh miasm; and I have no doubt this is the sense intended to be conveyed. In the first place, I may remark we know nothing whatever of this marsh miasm; we as- sume the existence of such a substance; and, as has been already stated, some have even ventured to give it sensible qualities, as smell and specific gravity. This is certainly going quite far enough in mystery and darkness; but to say it directly affects the blood is a gratuitous assertion well becoming a true Cullenian, whose whole system of physic is founded upon, and carried on from page to page, by the most erroneous and weakest assumptions. This has always been my great objection to this system. Its author lost sight of the true Hip- pocratic maxim in the investigation of diseases. Cullen declared that there "are more false facts in medicine than false theories;" and on one-occasion he asserted in his lectures, that what were called " medi- cal facts were nothing more than medical lies." It will be seen, that whenever Cullen came to a difficulty, instead of waiting patiently for an accumulation of facts to enable him to investigate all its bearings, he made a leap over the obstacle by assuming a certain thing for a fact. He established a system of special pleading, and a symptomatical pa- thology, which have been exceedingly injurious to medical investiga- tions; and it will soon be generally acknowledged that his labors have retarded, rather than advanced, the science of medicine. In conclusion, I wish to impress upon the minds of my readers, that by venesection in the cold stage of intermittents, we stand upon vantage ground, by affording our patients the benefits of the following circum- stances: 1st, The injury which in many cases results from the continuance of the venous engorgement, which so constantly leads to organic dis- eases, is avoided. 2d, The danger proceeding either from the want of sufficient re-ac- tion, or from its excess, is also avoided. 3d, The practice prevents debility, in a direct manner, by saving the vital fluid. 126 INTERMITTENT FEVER. 4th, The chance of a return of paroxysm is diminished; or if it should recur, the force of the attack will in general, be weakened; and in that case a most important point will be gained, by affording an op- portunity for the administration of other remedies, as bark or arsenic, which might have previously been exhibited in vain. 5th, Experience has also taught me, that bleeding in the cold stage is far more efficacious than bleeding during the hot stage, or in the in- tervals. Several cases are quoted, in which bleeding was had recourse to in the hot stage to moderate threatening symptoms, but without preventing a return of the disease at the regular period; and in these same instances, bleeding in a subsequent cold fit, had the effect, not only of stopping the existing paroxysm, but of preventing its return. If any other evidence was wanting to show the advantage of a radi- cal change in the treatment of intermittent fevers, it will be readily found by contemplating the results which befell one of the finest armies Great Britain ever sent from her shores, and which went to Wal- cherenon the 5th July, 1809. The prevailing disease was intermittent fever, and in the course of six weeks, S000 sick, were sent to England, and 3000 more soon followed. While seven officers and ninety-nine men were killed in action during the whole campaign, we find that forty officers and 2041 men died from disease. It is further stated in the offi- cial returns laid before parliament, that several months after the return of the army, there were on the sick list 217 officers, and 11,296 men ! A curious and an interesting fact was communicated to me by Dr. Foot, (who served with the 17th regiment in India,) when he did me the honour to attend my lectures,—that some Persian physicians apply ice to the surface of the body in the cold stage of intermittents, and, it is reported, with good eflect. I have also heard that it is a practice with some in India, to use the cold affusion. It is proper, also, to mention the plan of preventing the paroxysm upon the first appearance of its approach, by applying tourniquets to the extremities, which was first noticed by Dr. Kellie, in the 1st and 2d volumes of the Annals of Medicine.* The tourniquets appear to act, by confining the blood in the extremities, and preventing so much at least of the congestion in internal organs. Treatment of the hot stage.—The best treatment which can be pursued in the hot stage, is, to remove the bed-clothes as far as the season and the patient's feelings will admit; to sponge the extremities * This curious remedy is mentioned by Boisseau, p. 523, as if it were the ori- ginal invention of Lallemand. INTERMITTENT FEVER. 127 with water; to use cold drinks; and, in fact, to employ every means which can diminish the temperature of the body. If there be symp- toms of local inflammation, bleeding is to be had recourse to, either general or topical, which has always been employed, by judicious practitioners, under such circumstanceg. I need not speak of febri- fuge and diaphoretic mixtures, which are very good for the druggist, will assist in filling the pockets of the routine practitioner, and suit the notions of a symptomatical physician. It is more than doubtful, whether such medicines ever diminished the violence, or shortened the duration, of the hot stage of an intermittent. Treatment in the sweating stage.—When the sweating stage com- meccs it must be encouraged until the uneasy feelings are relieved, or at least mitigated. Great injury is done by allowing patients to perspire longer, by which they are not only unnecessarily weakened, but the subsequent paroxysms of the disease are in general rendered more violent. The best way of arresting this stage, is, to change the linen, after drying the patient carefully with towels, and to place him on a couch. A second paroxysm has been frequently traced to a chill, oc- casioned by the coldness of the damp clothes, towards the termina- tion of the sweating stage. Should there be no marks of any local inflammation, the patient may be offered light nourishing food, and even wine if necessary. Treatment during the interval.—The first thing to be done, is, to determine whether or not there exist any local disease, and if so, what is its nature and seat? Medical men have hitherto deceived themselves very much by treating this disease, as well as many others, merely from its name; because it is intermittent fever, bark must be prescribed? Another error into which they have fallen, is, that they imagine the only organic lesions which take place exist in the liver and spleen, whereas the brain and the lungs suffer, perhaps, more fre- quently. I have seen fatal affections of the heart also arise in the train of consequences from intermittent fever. Bronchitis is also of fre- quent occurrence. These facts as stated from my own experience; and, except the last respecting bronchitis, they are fully proved by the cases and dissections recorded by M. Bailly, as well as by the facts which are to be found in the works of Pringle, Cleghorn, Chisholm, and others. If any organic disease exist, bark will be injurious, until it be either mitigated or entirely removed. Sir James Fellowes (Reports, page 350) states, that the dissections of those who died, discovered to us a scries of morbid appearances of which we had no suspicion, and they 128 INTERMITTENT FEVER. enabled us to account for many of the phenomena of the complaint, and to form a more rational plan of treatment than that which we had at first adopted. M. Bailly came to the following practical conclusion: that he bled, to dispose the system to receive the action of the bark, and that he has suddenly, by such means, subdued intermittent fevers, which had previously resisted all other means; and he assures us, at page 366, that although he would not altogether prescribe bark, yet he believes that bleeding alone, in most cases, above all, in our climate, would bring about a more substantial recovery. He also makes a very strong statement at page 375. " In the commencement of an inter- mittent fever, (says he,) one is almost always sure to destroy it by a large bleeding; and he shows that this disease is not so fatal to poor, debilitated subjects, as to those who are better off, and better fed. For example, the mortality at Rome, where great misery prevails, is 1 in 26 of the whole population; whereas, in the marshes in the neighbor- hood of the Sienne, the mortality is in the enormous proportion of 1 to 10 of the whole population. He also assures us, at page 383, that we are not to dread debility; that those patients who were bled by himself abundantly, and at short intervals, not only were not depress- ed by this debility, but acquired in a few days a state of strength and health which they had not known for a long time. Had this distin- guished author been aware of the safety and success of my plan of bleeding in the cold stage, he would not have made the complaint, that in the worst intermittents, that is to say, those in which the pa- tients died in the cold stage, he had " not time to employ bleeding." Speaking of the advantage of bleeding in this disease, he says at page 383: " Car j'en excepte toujours les fievres intermittentes pemicieu- ses, dans lesquelles on n'aurait pas le temps d'employer la saignee, si on ne se rendait pas maitre de mouvementnerveux par ce precieux an- ti-periodique." It is in such instances that the great advantage of bleeding in the cold stage is most apparent. In some of M. Bailly's cases, stimulants and bark, in considerable quantities, were given without benefit, and in the majority the pulse is described as having been strong. Bark has been long in use, and although I never denied that it had virtues, yet when given in substance, in the large doses which are ad- mitted to be necessary, I have so frequently seen it do mischief, that the question has often suggested itself to me, whether it was not more injurious than beneficial? It seems to be injurious, in many cases, by overloading the stomach and bowels with indigestible ligneous fibre, and I have seen it cause serious intestinal irritation, as displayed by INTERMITTENT FEVER. 129 griping pains in the bowels, diarrhoea, and painful tenesmus. On ex- amining the stools in these cases, they seemed chiefly to consist of bark, with a considerable quantity of mucus, occasionally tinged with a little blood. That preparation of bark, which is known by the name of the sulphate of quinine, is the greatest improvement in modern pharmacy, and the knowledge of its beneficial effects in simple inter- mittents, affords sufficient proof of the virtues of the substance from which it is extracted; yet this remedy, all-powerful as it is, is useless in the cold stage, and must also fail in cases complicated with organic disease. Dr. Fordyce, who had great experience in the treatment of this disease, states, that, " in many cases of perfectly regular tertians, the most skilful practitioners have been baffled in the use of Peruvian bark, and every other medicine recommended as useful in this disease." My youthful readers may rest assured, that the same observations are equally applicable to the sulphate of quinine; yet they will meet very probably with many practitioners, who will assure them that they have never seen a case, in which bark, exhibited in substance, or in any other form, has failed in their hands. When they hear such state- ments, they may be satisfied that such practitioners never met with a severe case, or that there is some subterfuge. Some medical men, it is but charitable to suppose, are in the habit of deceiving themselves; for I have heard of many who allege they cure every case of fever, and every case of inflammation, by brandy, port-wine and beef-stakes; and that the patients are to be regarded as in no danger, if they can be only got to swallow plenty of these articles. They also state that they carry lancets in their pockets, but they never use them. The sensible part of the profession regards any man as a quack, or an im- postor, who asserts such universal success in the treatment of fevers and inflammations, and particularly by such means. Those who are young in the profession, may rest satisfied that no means hitherto devised can be universally successful; and the cases have been ahead}' pointed out, in which the sulphate of quinine may be expected to be beneficial, as well as those in which the same happy result is not to be looked for. It cannot be too strongly impressed upon the mind,that experience has taught me to beware of any prepara- tion of bark, while the patient has fever, or complains of oppression at the praecordia. Sydenham's recommendation of prescribing bark in the intervals, has been supported by subsequent experience. Bark is given in sub- stance, in decoction, infusion, and in extract; but no one who has seen the superior efficacy of the sulphate of quinine, will, 1 am persuaded, Vol. 1.—17 130 INTERMITTENT FEVER. if he can obtain it, ever use bark in any of the other forms. With respect to the doses of quinine, Andral states that Lerminier has pre- scribed it in a very great number of cases, in two doses of three and four grains each, with an interval of half an hour,four or five hours before the paroxysm. And he assures us,that given in thismanner,it has almost al- ways cut the fever short. In some cases, the fever has been equally pre- vented, by the exhibition of the quinine twelve or fifteen hours before the paroxysm. Once the quinine was given by accident in the middle of the cold stage, and that paroxysm was neither weaker nor more in- tense than the preceding one. The greater part of those individuals who took the two doses of three grains each, had slighter paroxysms than before; but the fever was not suddenly cut short, as it was in those who took the two doses of four grains each. He also states that in two cases the sulphate of quinine did not subdue the fever till the dose was increased to twelve grains; and Larminier gave three indi- viduals twenty grains each during the day, stopping the fever without producing any accident. But with several other patients, to all ap- pearance in the same circumstances with the preceding, a few grains of the sulphate of quinine created troublesome nervous symptoms, such as violent palpitation of the heart; oppression; the globus hystericus; general uneasiness; flying pains in different parts of the chest and ab- domen.* The manner in which I have prescribed quinine, is to give three doses of five grains each, with half an hour of interval immediately be- fore the expected paroxysm; or three grains every half hour, begin- ning about three hours before the expected paroxysm. I have taken three and five grains, without feeling any thing unusual, and 1 after- wards ventured upon ten, but a violent headache followed, which continued for nearly three days; I have given ten grains, however, to others, on two or three occasions, without producing any such effect. Arsenic has been long in use in intermittent fever, and there can be no doubt that it has often proved serviceable. Fowler's solution is the preparation now in general use, under the name of liquor arsenicalis: the dose is from two to twenty drops twice or thrice a day. Other tonics and bitters have been recommended; the best of these is the in- fusion of quassia. Opiates have been exhibited, immediately before an expected paroxysm, sometimes with benefit, but they generally produce violent headache. Laxative medicines, to keep the bowels open, form an essential part of the treatment; and in general, the stools should be examined. I have met with cases which resisted * CUnique Medicale, p. 488. [intermittent fever.] 131 every remedy, till it was ascertained that the patients had given erro- neous accounts respecting the number and appearance of the stools; and upon the bowels being put in proper order, the disease has given way without further trouble. From the idea that intermittent fever is a disease of debility, many practitioners give nourishing and stimu- lating diet, with wine, in all cases; but after the pathological account which I have given, and the appearances found on dissection, a word more need not be said to show the impropriety of such conduct. In some instances it is beneficial, where there is no local disease; in others it must prove prejudicial. The patient should be clothed according to the season of the year, and the temperature of the climate. He should avoid exposure in bad weather, and particularly in our climate dtiring the prevalence of easterly winds, and keep to the house after sunset, till he be sufficiently recovered. [Our author has gone somewhat fully into the account of the treat- ment of intermittent fever, but has devoted the greatest part of his de- tail to the question of the propriety of blood-letting in the cold stage. We have no doubt, that under certain circumstances it possesses all the merit which is by him attributed to it; but certainly, in our climate, it is not applicable to all cases indiscriminately. In some forms of this disease, at the very commencement of the paroxysm, the prac- titioner is imperatively called upon to abstract blood, either gener- ally or topically, to prevent the speedy advance of violent internal congestions, and at the same time to call in the assistance of revulsive applications; as for instance, where the invasion is ushered in with apoplectic symptoms either of the brain or lungs. With regard to the exhibition of quinine, some interesting remarks remain to be presented. We would wish to be understood as not ac- cording with the practice of administering quinine in the large and frequently repeated doses advocated by the author. In this country it is seldom requisite to administer more than twelve grains during the first interval, and half that quantity during the following interval, to cure nearly all the cases which occur. Instances, however, frequently present themselves in which the exhibition of a larger quantity than is necessary to attain the end, would be positively injurious; so that practi- tioners have adopted the safer plan of giving a grain each hour,and limit- ing the amount to the number of grains specified. It is stated that the ex- hibition of this indispensible remedy sometimes fails: it is therefore im- portantto inquire into the causes of failure,and how they may be avoided. With regard to blisters, and all stimulants, in fevers, there is said to be a specific point where they are to be employed: if they are applied before this has been attained, increase of the affection is the consequence. This 132 [intermittent fever.] point is a state of reduced local or sympathetic excitement in organs which, when stimuli are applied to them, will not cause reaction to be transmitted from one to another. To render the meaning more comprehensible, when an organ is in a state of high irritation, and pro- duces sympathetic excitement in others, the application of a stimulant to any one of those secondarily influenced will be transmitted back again to the original organ, and be followed by an aggravation of the affection. Now if the sympathetic irritations are sufficiently dimin- ished, to allow of revulsive stimulation without affecting the primary location, its employment is beneficial. The same is the case with quinine. There is a point of excitement, above which its use is posi- tively injurious; and if employed, its therapeutic effect is counteracted. Failure is attributable to two causes. Should the stomach be greatly irritated the quinine will be rejected, and the attempt to exhibit the medicine foiled: but if this should not occur, it may arouse sympa- thetic effects which are equally embarrassing. There is a strong pre- disposition in this concentrated preparation to determine the flow of blood to the head, followed by the most disagreeable nervous symp- toms: hence, if there be any predisposition to the sympathetic trans- mission of irritation, the quinine will augment its energy to an alarm- ing degree. To allow therefore the best chance of the medicine pro- ducing beneficial effect s, great care must be taken that too much gene- ral excitement does not exist in the heart and arteries; that the sto- mach is properly prepared for its reception; and lastly, that the sympa- thetic disturbances are not exalted beyond the normal standard. Cases do exist where it is all important to bring the patient under the in- fluence of quinine as soon as possible, from the danger of a repetition of an alarming paroxysm. Under these circumstances there are two resources held out—one by means of injection into the rectum; the other by its application to the skin. Both of them present the advan- tage of avoiding the effects just mentioned, as its sympathetic action will not be aroused. But some slight delay will be occasioned in the latter case to prepare the surface for its reception, by the application of vesicatories. The following case confirms these remarks. Mr. H. aged 32, bilious sanguine temperament; has been subject to acute attacks of inflammation of the bowels; lately returned from a jour- ney into the interior of Pennsylvania, and arrived at home Aug. 29th 1835. During the few days after his return complained of feverish- ness, with disordered digestion, and finally confined himself to bed with confirmed fever. This for a few days assumed the continued form, when it became intermittent, two paroxysms existing on the 24th, last- ing from daylight until midnight. [intermittent fever.] 133 25th, Free from fever; pulse 95 and soft; skin moist. From the first invasion; when the fever was present, there was more or less evidence of exalted excitement of the brain. As his bowels were not open, prescribed a dose of oil, to be followed by quinine. At midnight was called in haste to see him, and found that he was labouring under vio- lent determination to the head, with stupor; head intensely hot; pupil contracted; breathing hurried and oppressed; skin hot and moist; pulse 140, quick and tense; dryness of the mouth, and when roused to drink swallowed with avidity, relapsing into the state of stupor. He had been in this condition two hours. Applied leeches and ice to the head, a hot pediluvium to the feet, followed by blisters to the ancles, and ad- ministered ice-water as drink; an injection was thrown into the bowels, which produced a stool. In an hour he was much relieved; pulse 112,softer, and fuller; skin reduced in temperature; disposed to sleep naturally. 26th, 5 A. M. stupor returned; eye again contracted; pulse oppressed; venesection gx, when he was relieved and completely himself; thirst continues intense; blisters were now applied to the stomach, back of the neck and arms, and during exacerbation of fever in the course of the day, were withdrawn and poulticed: continue ice to the head and ice-water to drink. In the evening there was freedom from fever, when the blisters were dressed with quinine, no recurrence of the paroxysm took place afterwards. A gradual abatement of the gastric symp- toms followed, and on the 8th of September he was convalescent. In this case the paroxysm of the night of the 25th, was evidently brought on sooner by some hours, in consequence of the sympathetic effect of the quinine upon the head, producing threatened apoplexy, and defeating the object of administration.] MALIGNANT REMITTENT OR YELLOW FEVER. This is a fever in which there are remarkable remissions, which are followed in a few hours by exacerbations; so that it bears some resem- blance to an intermittent. This circumstance has led Cullen to iden- tify them; and in his definition of intermittents it will be observed that he has embraced remittents also:—of the last he gives no separate definition. Remittent fever is a disease of warm climates, and when the skin is yellow it has obtained the name of Yellow Fever. The milder forms depend upon general functional derangement, which runs more quickly into disease of structure than is observed in the fevers of this country. Remittent fever has a very wide range of character; 134 YELLOW FEVER. modifications of the complaint occur without end, according to the organ or organs affected, the character of that affection, the constitution and habits of the patient, and the locality of his place of residence. In its severest form, the viscera of the three great cavities are implicated from the first onset of the disease, and there is no complaint in which the appearances on dissection may be so truly predicted. Symptoms.—The disease begins, sometimes with great excitement and without rigor; on other occasions, the rigor is severe. Generally speaking, there is some previous indisposition, such as headache and giddiness; want of appetite; symptoms of indigestion; oppression at the praecordia; constipation of the bowels; a feeling of debility and fainting; but of all these, oppression at the praecordia, some degree of giddiness, headache, and constipation of the bowels, are the .most fre- quent^ premonitory symptoms. Sometimes it happens that the patient dies before re-action takes place, but this is comparatively rare; some- times cases occur where the seizure is sudden and unexpected,—the patient is struck down, as it were; he loses his senses; irritability of the stomach soon appears; black vomiting ensues, and he is carried off in the course of thirty-six hours. " It often occurred," says Dr. Fergusson, "to a well-seasoned soldier, monnting the night-guard in perfect health, to be seized with furious delirium while standing sen- try, and when carried to the barracks, to expire in all the horrors of the black vomit, within thirty hours from the first attack." This, it must be confessed, is the most severe form of the disease. There are many varieties, concerning each of which it is impossible to treat in a work like the present. The most frequent form of the disease, is that in which, after the rigor, which may be more or less severe, there quickly succeed violent re-action, heat of skin, and de- termination to the head, announced by the following well-marked symptoms; flushed face; conjunctiva injected; the eyes look heavy, and often feel burning; the expression of the countenance often leads an experienced person to judge correctly of the severity of the attack. The respiration is hurried and frequently laborious, often attended by- cough, and the patient occasionally sighs, and seems to gasp for air. The head is thrown about from side to side; and the patient is exces- sively restless from anguish. Severe darting pains in the head are sometimes complained of, as also in the small of the back and down the thighs. There is sometimes a burning pain in the pit of the stomach; exquisite tenderness in the right hypochondrium; unquench- able thirst, with incessant retching of every thing taken into the stomach. The fluid ejected is mixed sometimes with a great deal of bile, and accompanied with a discharge of flatus, belched up, with YELLOW FEVER. 135 great violence. The pulse is various even in people similar in age, constitution, strength, and habits; but in plethoric subjects who are seized soon after their arrival in warm climates, the pulse is quick, full, and bounding for a few hours at least, after the re-action is fully developed. In some it is quick and not strong, and in others it is not particularly quick, and it is sometimes very irregular. The tongue is furred, perhaps red, but soon becomes parched and dark colored.—These symptoms indicate the first stage of this fever. An anxious and distressed countenance, redness and sense of heat in the eyes, flushed face, intense headache, quick or laborious respiration, burning pain in the region of the stomach, with great thirst and ex- cessive vomiting, announce a formidable disease; but, in my opinion, not so formidable and hopeless as another variety, in which there is some insensibility from the first, with coma, weak and oppressed pulse, and cold extremities. The duration of the first stage is very uncertain. In severe cases it lasts from twelve to eighteen hours, but in those which are slighter, it may go on for three, four, or five days. In the second stage the skin and eyes acquire a yellow tinge; the heat subsides; the head is confused, or delirium appears; the breath- ing becomes quicker and more anxious; the eyes begin to look glazed; the pulse sinks; the retchings are rather more violent; the matter vomited becomes thicker and begins to look dark; and if the person be sensible he desponds; he occasionally falls asleep, but instantly awakes in great terror; sometimes he starts out of bed furiously deli- rious, but instantly falls down in a tremor upon the floor; the tongue is always parched, and in general covered with a dark fur; and the skin becomes clammy. In this stage as well as in the first, there are often cramps in the belly and legs, which distress the patients much. The duration of this stage is also uncertain. The first stage sometimes terminates by a remission of the more urgent symptoms, when the patient and his friends indulge the fond hope that he may recover; indeed, these remissions often occur, but the deception is soon manifested by the recurrence of all the symp- toms in an aggravated degree. In the second stage there are remis- sions also, particularly towards its termination, when a hope of reco- very is again entertained; for although the vomiting be more frequent and more copious, all uneasiness generally subsides; but the pulse sinks, becomes irregular, and intermits; although it sinks in strength, yet it increases in frequency. Nothing is retained in the stomach; the matter vomited is of a dark colour, resembling coffee grounds, and is termed the " black vomit." The breathing becomes more labori- 136 YELLOW FEVER. ous; the tongue has perhaps lost its fur, it is shrunk, dry, and red; the eyes are sunk and glazed; the whole features are sharpened. As death approaches, the limbs become as cold as marble; there is a troublesome hiccup, which perhaps has existed throughout the whole of the second stage. Haemorrhage sometimes takes place from differ- ent, parts of the body; the abdomen is frequently as tense as a drum; and death steals on slowly, or takes place suddenly. The symptoms in each of these stages must of course vary much according as the brain, the lungs, and contents of the abdomen, are more or less affected. In some instances the functions of the brain re- main undisturbed, even to the very conclusion of the last scene; at other times, when there is extensive disease within the head, the de- lirium is more or less ferocious, or the patient is comatose; he exhib- its a variety of nervous symptoms, such as convulsions, rigidity of the extremities, tremors, subsultus tendinum, and picking the bed clothes; or where the head is more slightly affected, the senses are only occa- sionally obscured; the patient may be said to be lethargic rather than comatose; he is easily roused, and when roused his countenance has a drunken or besotted appearance. If the lungs be affected, the breathing will be altered from that of health; mere dyspnoea may, however, exist, without any structural lesion of these organs. There may be cough also, attended with pain, followed by expectoration. I never saw a case of remittent fever in which the functions of the chylo-poietic viscera were not very seri- ously involved, as indicated by nausea and vomiting, thirst, pain in some region of the abdomen, meteorism, and altered condition of the stools. It may be mentioned, also, that the functions of the kidneys seem to be almost, if not altogether, suspended, little or no urine being pass- ed during the course of the disease; and upon dissection the bladder is usually found much contracted. Another variety frequently met with in very sickly seasons, is that in which a person, after passing several restless nights, is able to go through some of his duties for the first two or three mornings; but this costs him a very great effort. His weakness increases, the bowels are out of order and constipated, or after having been for some time so, he may now complain of diarrhoea; he feels alternate chills and heats, but the least exposure makes him complain of cold; his stomach now begins to get irritable, he takes to bed, his senses become rather obscured, his breathing is affected in no other way than being short, and he cannot,even when he makes an effort,distend his lungs freely; he complains most of oppression at the praecordia: sometimes a re- YELLOW FEVER. 137 mission of most of these symptoms takes place, and his skin, which was never hot, and his pulse, which was never full, quick, and bound- ing, are now felt to be nearly natural; but in a few hours the symp- toms become aggravated. The patient is more inclined to he coma- tose than restless; he complains now perhaps ok violent pain in some region of the abdomen; the breathing is oppfessep^ th*extremities cold and damp, while the surface of the abdomen and thorax is hotter than natural; hiccup comes on, the coldness steals; onwards to the trunk, the pulse sinks, the countenance looks ghastiyjandthe patient's fate is quickly sealed. ' . . ■ In a work like this, it is impossible tp describe all the varieties of remittent fever which occur in warm countries,.. Sorti|g£imes the brain is the organ chiefly affected, when the symptoms are what may be called cerebral and nervous. In another set of cases, the disease is concentrated on the lungs, when the symptoms will vary accordingly. In another set, the different organs within the abdomen may be af- fected, producing other varieties; and of these there may be various modifications and complications. % Appearances on dissection.—These appearances vary much, ac- cording to the duration of the disease, and tHe organ which has been chiefly affected; some dying in the first stage,'when we must not ex- pect to see much, if any, appearancejoI inflammation. Some patients may have been largely depleted, and we shall therefore see less vas- cularity in their bodies than in those subjects who have lost no blood. Some individuals may have died of remittent fever, with organic le- sions produced by previous diseases. All these circumstances must be kept in vie^w when we are employed in the investigation of mor- bid appearances. Some blood is generally found in the heart and large vessels near it, and also in the lungs, if the individual have not survivedjong, and not been largely depleted. Pleuritic effusions are sometimes seen,and recent adhesions; the lungs themselves, in some instances,show vari- ous stages of inflammation, and the bronchial tubes are extensively diseased. In the abdomen, as in the thorax, various lesions are occa- sionally observed, viz: the results of peritoneal inflammation; morti- fication of the bowels; the liver pulpy, soft, very yellow, and easily broken down; sometimes its structure is completely destroyed, and it has been described by some authors to be in a state resembling "rot- ten cork." The spleen has been found altered in the same manner. The stomach and bowels, when slit open, are found to contain more or less of the dark coloured matter which has been vomited during Vol. I.— »S 138 [yellow fever.] life; and the mucus membrane very vascular, of a deep red colour, not in depending .portions only, but over a great extent of surface, sometimes throughout the whole. Until lately, it was not much the fashion to examine the mucous membranes minutely; and we still want information on the following points:—Whether the vessels which make such an appearance are in the mucous membrane or not? Whether the whole thickness of the intestine is discoloured or not? Whether this colour is owing to in- flammation or infiltration? At what particular points ulcerations are most frequently met with, together with a particular description of the appearances of the ulcerated surfaces, and the adjacent mucous membrane. And it would confer a lasting favour upon me, and a benefit on science, if some enthusiastic pathologist would take the t trouble to inject portions w^th vermilion and size, and send them to this country, together with sketches showing the recent vascular ap- pearances; if to enrich my rapidly increasing museum, the greater obligation will be laid upon me, and no remuneration which it is in my power to bestow, will be thought too great a sacrifice for such a boon.'' [The late lamented Dr. Lawrence has left the notes of fourteen cases of yellow fever, examined by him, in the city of New Orleans during the years 1S17-18-19,—which contain the following interesting facts. In all except one, it was found that the stomach presented the appearances of active inflammation, particularly throughout the mu- cous surface of the larger curvature. The case which formed an ex- ception, exhibited the stomach of " a dark dirty colour in some parts of its internal surface." The small intestines were, in every case, in a state of inflammation, particularly the duodenum, which in several instances was marked with dark livid spots. The stomach of.»ne in- dividual was " very large, and distended with air, containing some black, coagulated stuff mixed with a mucous substance. This mucous substance was very copious, and much resembled the villous coat of the stomach. In fact I had no doubt, but that some of it was the vil- lous coat; as this coat, particularly about the middle of the stomach was remarkably thin, and could be taken off with great ease. In some places were dark-looking patches, intimately united, resembling the coagulated substance in black vomit. I soon had scraped off the mu- cous coat from these places, and the dark matter was removed with it as if it was the mucous coat itself, merely changed in colour. This would lead to the inference that the black vomit is nothing but a re- jection of the disorganized villous coat of the stomach." The luno-s * It may be mentioned, that nothing alTords me greater pleasure than to spend an hour in my museum, with any pathological enquirer. [yellow fever.] 139 and other viscera were generally' found in a sound condition, with casual lesions existing in them, some of which were attributable to ancient disease, others to that which was of more recent origin; but there was no uniformity of occurrence. Dr. Jackson in his history of the epidemic yellow fever which in- vaded Philadelphia in 1820—has presented the result of the post mortem investigations which were made. The following details are worthy of attention. "The brain did not exhibit marks of active in- flammation. The veins of the dura and pia mater were mostly turgid with blood. Effusion of serum under the »dura mater was found in three cases which had terminated with convulsions, and a larger propor- tion of it than ordinary appeared in the ventricles. ' The substance of the brain in no instance displayed any strong marks of disease. The viscera of the thorax presented no appearances that indicated their partaking largely of the diseased action of the system. It was among the abdominal viscera, that was to be discovered the evidence of the fatal storm, and of these the stomach was a uniform and principal sufferer. This viscus presented different appearances. I was much surprised to find it, on the first examination I made, without any marks of inflammation. The villous coat was of a rather whiter as- pect than is usual, but a considerable quantity of black, coffee-like fluid was contained in the stomach. In eight or ten instances a nearly similar state of that organ was discovered, there being no inflamma- tion, or a slight blush, mostly about the cardiac portion, being alone observable. The flowing out of the matter which constitutes black vomit, appears to have relieved the loaded vessels in those cases, and to have terminated the inflammation; but the death of the organ still ensued. It would seem, as I believe Dr. Physic has remarked in his dissections, that the formation of black vomit is an effort of nature to terminate violent inflammation of the stomach. But in the far greater number of instances, the stomach was highly inflamed. The inflam- mation was always confined to the villous coat, the muscular and peri- toneal escaping the affection. It was not uniformly diffused over the surface, but would be deeper in one part than another. The cardiac portion was generally more inflamed than the pyloric, and sometimes a greater intensity was observable between the superior and posterior surfaces, a well-defined and distinct line separating them. No ero- sions or abrasions were discovered, though the villous coat was at times nearly livid, and broke with ease upon pressure with the nails. The vessels of the stomach were so turgid with blood, that portions of it cutout and dried have formed very perfect preparations, exhib- iting the ramifications of the vessels into their minutest divisions. 140 [yellow fever.] The matter constituting black vomit was met with in every examina- tion. In two instances, in which it had been thrown up during life, with the usual characters, a fluid more resembling blood was found after death." The liver varied in appearance, never constantly pre- senting the same aspect: it was usually gorged with blood, but not al- ways. Gall-bladder sometimes distended with bile, the colour and consistence of tar. In two instances, the internal coat and lining membrane of the ductus communis was inflamed. Spleen and pan- creas general!}' natural. " The intestines most commonly were more or less inflamed, not in a uniform manner but ifl patches. They were in one subject con- tracted in some parts so much, that the little finger could scarcely be passed through them, and were swelled and distended in other parts. Three or four introsusceptions were formed in this case, but which were unattended with any* inflammation at the spot where they ex- isted. This patient had taken large doses of calomel and had died strongly convulsed. The intestines always contained considerable quantities of black mucus, bearing a similarity to the flocculi of black vomit. In some cases it was evidently sanguineous. The uri- nary bladder was sometimes much contracted, and contained no urine, at other times small quantities were found in it. " The whole of the system of the vena portae was always distended with blood. It was at first supposed, that the blood being thus fluid, was in the dissolved state so often mentioned by writers. But Dr. Hewson, wishing to make some experiments, collected portions of it in cups. In the course often or fifteen minutes, it was firmly coagu- lated; and this was found in subsequent observations invariably to oc- cur. The notion therefore of the blood being dissolved in this dis- ease, frequently described by writers as observed in their dissections, is not correct. " The opinions that were held with respect to the nature of black vomit were various and loose, until the examinations instituted by Dr. Physic in 1798-99.—It was demonstrated very satisfactorily, that it proceeded solely from the stomach, that it did not partake in the slightest degree of the nature of bile, which had been the com- monly received doctrine; and in fact that the liver had no'share in its production. Dr. Physic considers black vomit to be a diseased secre- tion from the vessels of the stomach. This opinion is entitled to great attention, and is rendered very probable by the arguments and experiments with which it is supported. But from the great tumes- cence of the whole portal system always found distended with blood I am disposed to believe that the inflammation of the stomach and of ' j [yellow fever.J-' 141 the other abdominal viscera in this disease is venous,and not arte- rial, and arises from an engorgement of the veins extending to their minutest division and first origin. Should this view be correct, black vomit, it is not unlikely, may arise from a. sanguineous effbsion from the capillary extremities of the veins. The matter of black vomit does not maintain invariably, the^eamfe characters, but recedes more or less from, or approaches to, an appearance of.blood. I have seen se- veral cases in which the discharge tpwards the termination, became nearly sanguineous; and a similar fluid was also found in the intestines. " Dr. Rhees, the resident physician at' the city hospital, instituted a series of observations on the black vomit, with a solar microscope. Innumerable quantities of animalculae were ibund to exist in it A single drop containedkmany thousands, apparently a congeries of them. The black mucus of the intestines exhibited the same phenomena. When the fresh matter thrown from; the'Stomach was examined, the animalculae were alive, and in constant motion, hut if taken from the dead subject, or inspected after standing some time, they were always dead and quiescent. Comparative examinations were made of the dis- charges from the stomachs of*pat|ents ill with autumnal, bilious, and remittent fevers, but no similar appearances were discovered.] Causes. It has already been shown that the extremes of cold and heat are not very productive of disease. Fevers are produced more by sudden changes of temperature, or by heat Ctftjoined with moisture, than by heat itself, however intense^ The state of the mind has also a great influence, as well as the habits of the individual. It has often been remarked, that there is great mortality among troops after their first arrival in a tropical, climate. This is sometimes to be attributed to a want of due care on the part of government, in choosing the season at which they ought to arrive. I believea greater number of men will be lost during the first twelve months if they are landedatthe beginning of«thc rainy season,lhan at its termination; perhaps the loss will be doubje. Great care should be taken in the selection of the troops; none but well-seasoned soldiers should be sent out. Sir George Ballingall has written Very strongly and sensibly upon this subject, in his excellent work on some of the diseases inci- dent to the troops in India. No young recruit should be sent out to be made a soldier; all his drills and exercises should be completed in this country. When troops arrive in a distant country after a tedious voyage, it is natural to expect that theywihVindulge themselves in many ways be- yond due bounds. Cheap new rum, or a rare and abundant supply ef 142 yellow fever. delicious fruits, attract their attention, and do incalculable mischief- Some men leave England in the utmost state of despondency, and it will in general be Observed that.they are the first victims. New comers are also apt'fco indulge in drinking too largely of cold fluids, and sitting in a thorough draft when the body is over-heated; in fact it requires a considerable time before a European obtains knowledge to manage himself properly. Some are fool-hardy, and take no care of themselves whatever; and I feel convinced, that an amusement in which young strangers too frequently indulge, known in the West In- dies by the name oi"Dignity Balls" causes many a death. JVIany cases have come under my observation, in which fatal attacks of fever appeared to have been produced by inattention to the bowels; and I am convinced that it is a matter of the first importance to every one going to a warm climate, to keep his bowels-open by gentle medi- cine. Repeated observation has induced me to believe, that a person may very often be exposed to any or all the causes of fever, even in the most unhealthy situations, without being affected, provided his bowels be in a pr'oper state, and his mind free from apprehension. These are a few of the many causes of diseases in warm countries, entirely independent of the influence of contagion, marsh miasm, and epidemic influence. Pathology.—With respect to this part of the subjeet, I have little to say, except to refer to the general account already given of the patho- logy of fever. Remittent fevers have the same pathology as other fevers, only it will be found in general that the structure of more or- gans is involved than in the ordinary fevers of this country. But it may be noticed, that there is no species of fevers which upholds the doctrines of Broussais more Completely than the Remittent. Treatment.—There have been as great revolutions in the treat- ment of the fevers of warm climates, as in that of any other class of diseases with which I am acquainted. The supporters of the doctrine of putridity have, of course, always avoided bleeding even in the first stage, when they admit the existence of inflammation, for fear of the debility which they expect in the latter stages. They begin by clear- ing out the primae viae, and then have recourse to bark in very large doses, without regard to the state of the stomach, local inflammations or any other circumstances. This is the practice recommended by Clark, Lind, and others. They prescribed opium, for the purpose of keeping the bark upon the stomach, and gave wine and brandy in con- siderable quantities, with the view of supporting the strength, keeping off the stage of collapse, and preventing putridity. But it may be yellow fever. 143 stated without fear of contradiction, that his practice cannot be too severely condemned. • It should be recollected, that the stage of col- lapse must come on sooner ordater. No person can pass from a state of fever into that of health and strength; and the longer it is postponed the worse it will be for the patient, whose situation very much resem- bles that of an individual in debt, who puts off the evil day from time to time by various mean^, and when his creditors meet at last, he is found without means to pay, whereas, had he disclosed his real situa- tion sooner, the strength of his credit would have survived the shock without injury. The late Dr. Chisholm, about the year 1793, introduced the plan of affecting the system with mercury as speedily as possible, employing bleeding in small quantity, and only occasionally, more with a view of enabling the system to receive the mercury, than as a powerful measure calculated to subdue the diseased action. Now my recom- mendation would be the reverse; to use bleeding early, as the chief means, in cases which require depletion, and mercury afterwards as an auxiliary. The celebatcd Dr. Rush bled and gave calomel to di- minish the increased action; arid the reason this practice did not main- tain its ground, is, that he trusted a little to the bleeding, and a little to the calomel, on the principle of gradually depleting the system. He rarely took more than ten ounces of blood at a time; and notwith- standing he repeated the bleeding from day to day, yet be never pro- duced decided effects upon the disease, although he sometimes took away from one hundred to one hundred and fifty ounces of blood. The practice woufd have been far more successful, had he taken away twenty, thirty, or forty ounces at once. When blqeding is thought necessary in this disease, it is trifling with the patient's lifeif the blood be not allowed to flow till some im- pression is made upon the disease, and upon the system; and it is im- possible to determine beforehand the quantity which will produce one or other of these effects. This is the kind of practice which was pur- sued by myself and many others who were in the West Indies twenty years ago; and it appeared to be attended with great success. Some practitioners trust almost exclusively to the action of mercury; and in India more particularly, it is deeply to be regretted that a great waste of human life has consequently taken place. Some years ago, Dr. Halliday, of the Honorable East India Company service, was, by order of the Marquis of Hastings, put under arrest, and deprived of rank and pay, for showing, by most incontrovertible evidence, that in the general hospital of Calcutta, the enormous quantity of 26 144 YELLOW FEVER. pounds of calomel were consumed by 886 patients. And that under . the digestion of this mineral, the .proportion of the deaths was 1 in about 64 of the whole sick list,—whilst under a more rational treat- ment, the mortality" wasreduce^ about one-half. In fact, that the mor- tality bore almost an exact ratio with the quarftity of calomel exhibi- ted. After a delay of several years, Dr. Halliday was restored to his rank by the express order, more than once repeated, of the India Di- rectors. This transaction has never been brought before the British public; but having carefully perused all the evidence, I have no hesi- tation in declaring, that as a piece of persecution, from beginning to end, there is.no parallel case to be found irt the annals of any free country. • Wherever. jljhe story is known, it must cause a blot, never to be effaced, upon the memory of the then Governor-General of India and all his advisers, military as well as medical.* The result of the practice,df tKe rising medical officers in India has fully corobo- ratedthe statement firmly madeby Dr. Halliday; and mercury is not now so much abused as it once was. And as pathological knowledge advances in India,'" which it is doing rapidly, mercury will be still less trusted to. It must be always kept in remembranceyhowever. that the liver suffers more frequently in the fevers of warm climates than in this country, and therefore mercury, under judicious management, cannot be altogether dispensed with.., , In 1796, the deaths" in the West Indies under Dr. Chisholm's mer- curial plan, were never, exceeded,,amounting to nearly one half of the whole number of troops. ^ The bold and decisive use of the lancet in this disease has met with .* an able and influential advocate in Dr. Jackson, who was Inspector of Army Hospitals in St. Domingo, and subsequently in the Windward Islands. This distinguished individual bled to the extent of thirty, forty, fifty, sixty, and even eighty ounces at once in the very * The author regrets want of sufficient space to speak more fully of the trans- action; but he cannot avoid" annexing an extract from a letter addressed by the East India Directors to the Governor-General, after full ipvestiga'fion. "In the mean time we authorise and direct you to remove the restrictions you have placed to the further employment of Dr. Halliday, unless stronger objections shall exist to his restoration, than those which have been reported to us in the proceedino-s under consideration. It appears to us, that your interference in the professional discussions which were brought under your notice, has been carried further than is desirable, or consistent with the improvement of medical science." Notwithstand- ing this communication, Dr. Halliday was doomed to undergo still further perse- cutions. YELLOW FEVER. 145 beginning; and he repeated the operation within three hours, if the first evacuation had not been productive of permanent benefit; after this he gave calomel in doses of from five to thirty grains, repeated every third or fourth hour. Bleeding has been strongly objected to, on account of the condition of the blood. In some cases it appears of a dark colour, and streaked with red and bluish lines; it coagulates very imperfectly, sometimes not at all, and does not separate any serum. It is in the state com- monly called "dissolved blood," and which announces, it is supposed, a putrid state of the whole body, and particularly of the fluids. This appearance does not deter me from repeating the operation, as 1 have been long aware, that it exists more or less in all severe cases of con- gestion; hence I have been frequently able to show it to my pupils, in cases of intermittent fever, in which I have bled in the cold stage; and also in cases of congestive fever. It has also been noticed by In- dian writers on cholera; a similar condition of blood may be seen in patients affected with cholera in this country, and has been observed in some severe cases of bronchitis. Dr. Rush says he paid no attention to the dissolved state of the blood when it appeared on the first or second day of the disorder; but repeated the bleeding afterwards in every case where the pulse indi- cated it. He states a fact which 1 can verify, that it is common to see sizy blood succeed to that which was dissolved. He states also, that he was never deterred by the presence of petechiae from blood-letting in cases in which the pulse retained its fulness or tension. Although the necessity of keeping the bowels freely open in this class of diseases must be admitted, yet I had not been long in a warm cli- mate before I observed the injurious consequences produced by strong drastic purgatives, and many individuals were lost by the constant ir- ritation kept up by this means. The appearances on dissection, too, warrant me in cautioning practitioners not to persevere too long in using strong purgatives; there can be no advantage from moderating irritation and increased action, if these be immediately re-excited. The common purgative formerly used in the West Indies, was ten grains of calcflhel and a scruple of jalap. Emetics have been often extolled, but I believe every experienced tropical physician will agree with me in cautioning young practitioners against their indiscriminate employment; irritability of the stomach is one of the most frequent and troublesome symptoms, and once excited, it is always difficult, in many cases impossible, to restrain it. I have seen emetics exhibited, and the vomiting has continued till death, in spite of every remedy. Vol. I.—19 146 YELLOW FEVER. The same caution is necessary with regard to those remedies which are employed for moderating the action of the heart and arteries. When in the West Indies, I have often regretted not having a com- mand of leeches; and I am persuaded, that upon a proper representa- tion, the government would take steps, at whatever expense, to secure a proper supply to the medical officers of the army and navy. There is no disease in which dissection reveals so many organic lesions; and the efficacy of abstracting blood in such cases by leeches is generally admitted, particularly after the severity of the disease has been broken by the lancet. After the publication of Dr. Curric's work, cold affusion became generally used in remittent fevers, but much mischief followed, and it has fallen into disuse. Dr. Currie has distinctly stated, that it is not admissible in cases where there is any internal inflammation; therefore, in the majority of cases of the fever now under considera- tion, the practice will be found to be injurious rather than beneficial. But when the skin is dry and burning, nothing gives the patient more temporary relief than spunging the body'with water, or vinegar and water, which ought to be very frequently repeated. The application of blisters, and other counter-irritants are highly serviceable after bleeding, &c. but should never be had recourse to in this, or any other fever, in the early stage of the disease. I have seen stimulants appear to save life, but in candor it must be mentioned that I have also seen them very prejudicial; and 1 believe that nothing in the whole practice of physic requires more caution and experience than their exhibition; but I shall speak more fully upon this subject when treating of the fevers which prevail in this country. The best stimulants are wine and brandy; in many cases where the stomach is irritable, brandy will be found to be superior to wine. In the last stage great care should be taken to support the heat in the extremities. Partly from the notion of the resemblance between remittent and intermittent fevers, and partly from this disease being supposed to be one of putridity, bark has been employed. By some it is recommend- ed throughout the whole course of the disease, by others only during the remissions, and in the last stage; but I believe it has done more mischief than good. I have often had to blame myself for bringing on an exacerbation, not only by the use of bark, but by nourishment and stimulants, during the first remissions; and a strong impression is left upon my mind, that it would be better for patients if less were done for them in the state of apyrexia, and also in the commencement [yellow fever.] 147 of convalcscnce. No doubt, however, can be entertained, that the sulphate of quinine will be of signal service in many cases. [The method of treating yellow fever by large doses of calomel has for years been pursued throughout the United States, particularly in the southern portions of our union. The efficacy of this practice has latterly been questioned, and physicians have in a great measure yielded to the change in public sentiment. It is at least evident, that the exhibition of the enormous quantities of mercury which have been given both in this disease, and in other forms of fever, is not at- tended with the unfailing success which alone could warrant its em- ployment; and the after consequences are so frequently destructive to health and comfort, that the opposite extreme of total proscription of this powerful article of the materia medica has been fallen into; a cir- cumstance much to be deplored, as in proper doses and at suitable pe- riods of the affection, its use is highly serviceable. The gastric char- acter of yellow fever appears at the present era to be well ascertained; and the clinical reports of those who have treated it in accordance with the pathological doctrines which are becoming every day more widely disseminated, afford evidence of the superior utility of strictly antiphlogistic measures. If the general system is affected with con- siderable reaction, venesection is required; but in most cases the prompt application of leeches, or cups, as near as possible to the dis- eased organs, is followed by a decided amelioration of the symptoms. They should not be placed, however, so immediately in contact as to run the risk of increasing excitement As an auxiliary measure, the sedative impression of cold has a beneficial effect, and is peculiarly grateful to the patient: iced drinks, ice applied to the head, if this organ presents symptoms of disordered action, and the injection of cooling enemata into the bowels, are the modes of application. The administration of small doses of calomel, or blue pill, will admirably promote the cure when the force of the local irritation has been re- duced; and it only rerflains to unlock the secretions and gradually lead them hack to a natural state. To sum up the most approved plan of treatment in concise terms, we are to remove all irritating causes still remaining; mild, soothing, diluent substances are to be administered, while local and general symptoms are to be relieved by the means just indicated. The allowance of such diet as is suited to the condi- tion of the digestive powers will be regulated by the principles which guide us in inflammatory conditions of the stomach. For evidence of the advantage of this plan we refer to the cases of Drs. Barton and 148 INFANTILE remittent. Harris, treated in New Orleans during the year 1833, and reported in the American Journal of Medical Sciences.] INFANTILE REMITTENT. Many diseases which occur in infancy and childhood have obtained this name, viz. inflammation of the brain and lungs, the irritative fever produced by teething and worms, rheumatic affections, &c.; in all of which, and even in cerebral and pulmonary inflammations, there are very remarkable remissions in young subjects. But the disease which is to be considered in this section is a febrile affection, which is in ge- neral found to depend on irritation, inflammation, or ulceration of the mucous membrane of the stomach and bowels. Symptoms.—The little subject is observed to be listless, fretful, and thirsty, and to pass restless nights, with some heat of skin. In a few days the skin is hot and dry, the thirst and restlessness are increased, the breathing is hurried, and the pulse very quick. The child is more uneasy and restless at night, but towards morning the skin becomes slightly moist, when it has some disturbed sleep; the bowels are con- stipated, or there is diarrhoea, but the former is more frequently met with; or there is frequent desire to go to stool, but little is passed; if there be any evacuation, it is discoloured and fetid. In colour, the evacuations are not always dark, but sometimes white, showing a de- ficiency of bile, and sometimes bluish, but always offensive, often mixed with mucus, and occasionally with a little blood. The child cries frequently, and draws its knees up to the breast,—it cries more when the belly is touched, which is hotter than the rest of the body, and tympanitic. It prefers cold water to drink, and frequently shows signs of increased abdominal pain after a copious draught; the stomach is occasionally very irritable, and every thing is vomited; the tongue, being at first moist and loaded, and occasionally very red round the edge's, soon becomes dry over a triangular space at the tip. On some oc- casions it is difficult to keep the hands and feet sufficiently warm, while the face is flushed and the rest of the body parched. If proper treatment be not soon pursued, the functions of the brain occasionally become disturbed, and it is difficult, in many cases im- possible, to determine whether or not disease of structure is going on in the head. On other occasions the respiration, which has been hurried from infantile remittent. 149 the first, owing perhaps merely to increased circulation through the lungs, becomes laborious, a troublesome short cough also appears, and in general, ausculation will announce a more or less extensive in- flammation of the bronchial membrane; and if the disease be not sub- dued, wheezing and expectoration will follow. Sometimes the child appears to be recovering for a few weeks, and then relapses; during the remissions he gains flesh and strength, but the abdomen remains tumid, and in this condition he may continue getting better and worse till the mesenteric glands become enlarged, or dropsical effusion takes place in the abdomen; the emaciation increases; there is no fever ex- cept at night; the appetite is occasionally voracious. In fact, the little sufferer presents all the symptoms of the disease usually known by the name of Tabes Mesenterica. Appearances on Dissection.—The chief traces of disease are found in the abdomen. Sometimes peritoneal inflammation seems to have been the immediate cause of death, and I have had many opportunities of ascertaining that inflammation of this tissue has been excited by the extension of ulceration of the mucous membrane, through the muscu- lar and mucous«tissues. The mesenteric glands are found very gene- rally enlarged, sometimes enormously so, and seem to consist of a cheesy-looking matter, which is usually described as depending on scrofulous action, but perhaps without good foundation. On cutting into the stomach and bowels, the mucous membrane will be found in various conditions, occasionally very vascular, thickened, softened, or ulcerated. The ulcerations in the ilium and colon strictly resemble those which I have afterwards to describe in the bowel-complaints of children, except that the whole mucous surface of the colon is occa- sionally involved in one sheet of ulceration, with a rough and ragged surface and hypertrophy of all the coats, as is observed in many cases of phthisis pulmonalis. When there is no ulceration, we sometimes see mere vascularity, with or without softening of the mucous mem- brane; the quantity of thick mucus adhering firmly to the surface is very great; and it is curious, that after being carefully removed by washing and wiping, I have seen fresh exudations take place during maceration, not only in water, but in spirits; and I have been sur- prised, after having laid by preparations for many months to find them again thickly coated over with mucus. Large abrasions are also sometimes found in the mucous membrane of the stomach, at the sple- nic extremitv which have penetrated through all the tissues at one point; in other places they appeared to be converted into a gelatinous mass. From careful examination, it would seem that this kind of 150 INFANTILE REMITTENT. disorganization is the effect of previous inflammation. This appear- ance has excited considerable interest of late years, and has been noticed on the continent by Cruveilheir and others, and in this country many years ago, by Underwood. The profession stands greatly in- debted to Dr. John Gairdner of Edinburgh, who has collected a great number of interesting cases, some of which occurred in his own prac- tice, and which will be found in the first and second volumes of the Medico-Chirurgical Transactions of Edinburgh. It has been stated in the description of the disease, that symptoms of cerebral and pulmonary disease sometimes become lighted up, but on watching the progress of the affection, these are observed not to form essential parts of it; nevertheless, the appearances sometimes found in the head and thorax,deserve to be mentioned. In the head there is generally effusion in the ventricles, and also between the arachnoid and pia mater, with great vascularity in the latter membrane. In the thorax, the most common morbid appearance is found in the bronchial membrane, which is vascular, and the tubes are more or less filled with mucus, which is to be described more particularly when treating of bronchitis. The substance of the lungs also shows various degrees of inflammation, and occasionally there are traces of pleuritis. Causes.—These are indigestible food, such as crude vegetables, sweet-meats, &c; the habit of allowing children to eat too many arti- cles of food at one meal; together with insufficient clothing, and un- wholesome food, to which the children of the poor are so frequently exposed. Teething sometimes produces symptoms like those above described. Pathology.—From this view of the phenomena of the disease, to- gether with the appearances on dissection, and the causes, the reader will have anticipated what I have to state respecting the nature and seat of the disease, that it depends on irritation and inflammation of the mucous membrane of the stomach and bowels, particularly of the latter. Treatment.—Abstinence from solid food is necessary; even bis- cuits, crusts of bread, and the pulp of oranges, frequently produce re- lapses. Leeches should be applied to the abdomen in all cases where there is much vascular action, pain, and much heat of skin, if gentle laxatives, frequently repeated, do not mitigate the symptoms. Fo- mentations should be applied to the abdomen; when the skin is hot and parched, sponging the body frequently with tepid water will often INFANTILE REMITTENT. 151 lake off the restlessness. The practitioner should be particular in all cases, but more especially in attending children, to examine the stools, and the quantity of clothes with which they are too often covered. A remarkable case occurred to me four or five years ago, which is worthy of being mentioned. A child aged seven was seized with some degree of chilliness, followed by reaction, thirst, want of appe- tite, nausea; the respiration became hurried, and he complained of considerable headache. He was ill for five or six days before I saw him, and had taken repeated doses of salts and senna. On examina- tion, I found the abdomen distended, tense, tympanitic, and somewhat painful to the touch; his thirst was considerable,the respiration quick, the face flushed, with some headache,and he complained ornoise and light; the tongue loaded with a white fur, moist every where but at a small triangular space at the tip, which was red, as were also the edges; he had no vomiting, but a dislike even to the smell of solid food; he was very uneasy and restless, passed sleepless nights, and the pulse was quick, but not particularly strong. During the course of eight days, leeches and fomentations were frequently had recourse to, and always with marked relief; but it was always of short dura- tion. Gentle laxatives were frequently given, and injections admin- istered, but all to no purpose; the stools were slimy and scanty, and as the child had been so long witffout even taking gruel, it was ima- gined that the bowels were empty. The abdomen was blistered. At last something excited my suspicion respecting the state of the bow- els, and castor oil was given on the fourteenth day, every second or third hour, after a moderate dose of calomel and jalap. On going to stool, he complained very much of pain; he was observed to strain most violently; and after some time, he passed what appeared to be a very large fetid stool, which surprised me very much; it was so large that 1 was induced to examine it minutely, when three hard masses were discovered, surrounded with a great quantity of mucus. Upon close examination, they proved to be a dollar biscuit, and two pieces of solid meat; the biscuit was soft, but quite undigested and whole, with the exception of its margin, part of which had been broken off; the depressions generally made on the surface of biscuits were quite distinct, as also several of the letters of the baker's name. This bis- cuit was seen by a great number of gentlemen who were attending my lectures at the time, and is now in my museum. One piece of meat was large, and must have formed a good mouthful; the other was small, but both were quite unchanged by digestion, and not so putrid as might have been expected; it turned out that the boy was 152 CONTINUED FEVER. frequently in the habit of bolting whatever he had in his mouth, without mastication. His recovery was progressive after he got rid of these substances. , If the disease become chronic, occasional leeching, perseverance in gentle laxatives, a nourishing, but mild and bland diet, a long perse- verance in counter irritation on the surface of the abdomen, by means of the tartar-emetic ointment, and an occasional warm bath, are the best remedies. If there are evidences of effusion into the abdomen, with scanty secretion of brine, a preparation of calomel, squills, and digitalis, in doses proportioned to the age and strength of the patient, will be found serviceable, together with drinks acidulated with cream of tartar. •Many of the students attending my dispensary, have seen remarkable recoveries under the plan of treatment above described, even in cases which at first appeared to be hopeless. CONTINUED FEVER. Cullen and others maintain, " that there is no such disease as that which the schools have called a continued fever." There can be no doubt, however, that there is such a class of diseases, if we look at na- ture; and that Cullen would have%een it if he could have looked through any other medium than that of his own erroneous theories. Cullen's definition—"Fevers, without intermission, and without being: produced by marsh miasmata, but with remissions and exacerbations, though not always considerable, continuing; two paroxysms in each day." Although all his definitions are bad, this is to be regarded as almost the very worst. Often have I seen slight continued fevers termin- nate in regular intermittent, and intermittent in continued fever, at least as much as any fever can be said to be continued; continued until death closed the scene, or rather, 1 should have said, till that stage of collapse took place which precedes death. This definition must be admitted to be too fine-spun; for if there is no continued fever, it may be also said there is no continued inflammation of the brain, or of any other organ. In all fevers, as in all diseases, there are intervals in which the patient is easier, and appears, perhaps, rather better; and there are also nocturnal exacerbations, which may be partly attributed to the sick being worn out and made worse by fatigue, heat, light, and noise during the previous day. All the fevers which are to be described in this class, are called "idiopathic," as well by those writers who have identified in their own CONTINUED FEVER. 153 minds fever with inflammation, but who will not allow the existence of" any primary local disease,'' unless that disease be one of inflam- mation; as by others, who deny the local existence of local inflamma- tion in fever. Cullen belonged to this last class, and he states that he never had seen a case of inflammatory fever but one, therefore he en- deavoured to place these fevers altogether beyond the pale of patho- logy. In this spirit has he framed the definition of fevers: " After languor, lassitude, and other signs of debility, pyrexia; without any primary local disease." The reader will see at once the absurdity of this symptomatical pathology which, denies to any fever whatever, except hectic, any primary local disease; for Cullen is subsequently compelled to place inflammatory fevers as one of his orders; and although he gives a very common-place reason for calling inflamma- tory fever, "synocha" and an explanation that this term is not to be used in its "vulgar acceptation;" yet we are not to be told in the present day, that the pathology of a disease can be changed by a mere name, which any one may invent. All Cullen's disciples will he found to fall into the same error, but they become caught in their own net in describing the order synochus, which, according to them, is a compound fever, of an inflammatory nature in the first stage, and typhoid in the second. Cullen, in the 141st paragraph, makes the following statement; "In the case of synocha, {inflammatory fever,) therefore, there is little doubt about the propriety of blood-letting; but there are other species of fever, as the synochus, in which a violent re-action and phlogistic diathesis appear, and prevail during some part of the course of the dis- ease; while, at the same time, these circumstances do not constitute the principal part of the disease, nor are to be expected to continue during the whole course of it; and it is well known, that in many cases the state of violent re-action is to be succeeded, sooner or later, by a state of debility, from the excess of which the danger of the disease is chiefly to arise. It is therefore necessary, that in many cases blood- letting should be avoided; and even although, during the inflam- matory state of the disease, it may be proper, it will be necessary to take care that the evacuation be not so large as to increase the state of debility which is \o follow." It was Dr. Baillie's opinion, that typhus was as rare as Cullen states inflammatory fever to be. The truth is, that much depends upon the class of people among whom a physician practises, and the period of the disease at which he generally sees his patients. Our army and navy surgeons have to treat fevers in subjects well fed and clothed, Vol. I.—20 154 FEVER FROM FUNCTIONAL DERANGEMENT. and whose regularity of conduct is enforced by military discipline, which the physicians cannot expect among the inhabitants of St. Giles in London, and the Cowgate in Edinburgh. Therefore they seldom see pure typhus in their practice; and they will have to blame them- selves if they often meet with synochus; for they are too bold and in- telligent, and are to well versed in military tactics, not to attack the enemy before he gets possession of their stronghold; and they will be rarely found guilty of declining an engagement for fear of another enemy which may appear when they are weakened by the combat. Soldiers and sailors can very rarely conceal a fever; so that they are brought at once to the medical officers, who therefore see the disease early, and before it becomes complicated. A great deal also depends upon the treatment pursued in the first stage. If a physician were always afraid in the first stage of fevers to apply the proper remedies, when inflammatory symptoms presented themselves, lest a low or putrid tendency should subsequently occur, he will of course subse- quently see the compound fever "synochus" in its worst form. I have now to treat, first, of fevers from functional derangement; secondly, fever from inflammation; thirdly, fever from congestion; fourthly, a mixed form of fever, consisting of a combination of these three, but in which congestion generally predominates at last, com- monly called Typhus and Synochus. FEVER FROM FUNCTIONAL DERANGEMENT. All ages and classes of society are liable to this form of fever; but more particularly children, and those who have the inclination and means to overload the stomach and bowels with two much nourish- ment. It is not, in general, very formidable; but cases are occasion- ally met with which are abundantly alarming, and difficult to treat, from the impossibility of fixing upon any one organ which can be said to be affected severely, and yet all organs are out of order, giving rise to considerable constitutional disturbance. In some cases the symptoms are exceedingly slight for a week or ten days. The patient often feels chilly, which he is apt to attribute to the weather—increasing weakness and languor, which he thinks are owing to impaired appetite; he has rest- less nights, with burning heat in his hands and feet, and some thirst. At last his whole surface is hot; he perhaps goes to stool once a day or even twice, and he passes something that satisfies him that his bowels are right, when all the time they are constipated; and when a FEVER FROM FUNCTIONAL DERANGEMENT. 155 medical man is called, he will find him much in the following state: —skin parched; thirst considerable; tongue loaded with a yellow fur; without appetite; and the pulse perhaps about 95 or upwards; the urine scanty and high coloured. He complains of restlessness, par- ticularly at night; and general uneasiness, with oppression at the prae- cordia; he has slight headache; but complains most of pain in the lumbar region. The stools, when examined, will be found fetid, scanty, and adhesive; or watery and dark coloured, containing small hardened portions of feces, often mixed with a good deal of mucus. He loathes the article of food which in a state of health he most relished, even tea and coffee, milk, beer, &c. During the night his mind wa- vers; if he falls asleep, he appears restless and disturbed, and awakens with a start, the effect perhaps of a terrific dream; occasionally there is delirium. In some cases these symptoms continue even in a slighter degree for fourteen or fifteen days, and at last terminate in local congestion, or inflammation of some organ, and in the end as- sume the type which is termed typhoid; in fact, these are the cases, particularly where there is delirium, which many people call '-typhus mitior." This is the kind of fever which is in general cured by con- finement to bed; a steady perseverance in gentle laxatives, repeated two, three, and even four times a day; quietness, and abstinence from solid food. These are the cases in which wine is often prescribed by Brunonians, with far less detriment than solid food or beef tea. These are the cases in which the cold effusion has been so serviceable when used in the early stage, because there is as yet no local inflammation. Sometimes the fever is very sharp, and there is considerable excite- ment, with increased heat, general uneasiness,and delirium; the pulse above 100, full and strong; much oppression at the praecordia; the re- spiration hurried; the tongue loaded, perhaps dry and parched; and the bowels very much disordered. Treat??ient.—I have a great dislike to treat this form of fever, and for the following reasons: first, the patient has been long ill before he confined himself and sought for medical advice. Secondly, the symp- toms even then are apparently mild, while internal organs are serious- ly impeded in their functions. Thirdly, if inflammation have taken place in any internal organ, it is more difficult to treat that in pure" inflammatory fever, in consequence of the exhaustion occasioned by the previous indisposition. Fourthly, nothing can be beneficial if the greatest attention be not paid to the moral management of the patient, giving him laxative medicines at regular periods, and rigidly withhold- ing improper articles of food. Bleeding is certainly not necessary 156 FEVER FROM FUNCTIONAL DERANGEMENT. in all cases, but it is serviceable in many. I have had several cases of this description on my hands at one time during the autumnal months; and I have chosen patients resembling each other as closely as possible in habits, temperament, &c. I have drawn blood from some of these and not from others, and I never had reason to regret bleeding, but I often had to lament not doing it. It may be here mentioned, that bleeding is often employed from other motives than to cure inflammation. It is sometimes employed to moderate excite- ment, to diminish plethora, to alter irregular determinations of blood, and also to remove venous engorgements; but the only period for the lancet is the first days of the disease. In such cases bleeding may be objected to, as it has been even in inflammatory fevers, but I am sure it is safe in a majority of cases; and this conclusion has been strongly impressed upon me by observing the manner in which this kind of fever, in particular, frequently ter- minates. First, it sometimes terminates upon the appearance of an eruption, which eruption is generally urticaria; sometimes erysipelas, which acts beneficially by counter-irritation. Secondly, it often ter- minates by epistaxis. Thirdly, by diarrhoea, or by profuse night- sweats. And Fifthly, by abscess. Taking a common sense view, in reflecting upon these matters, I cannot help coming to the conclusion, that it is best for the practitioner to take the law into his own hand, and to deplete in cases which require it, before the strength of the body is reduced by the natural effects of diseased action. If in doubt about the propriety of general bleeding, the practitioner can have re- course to leeching; and in the class of cases now under consideration, the best place to apply the leeches is upon the abdomen or loins. Experience has led me to this practice, even in cases in which, al- though the symptoms ran high, no local inflammation could be detect- ed, and I can speak strongly of its success;—the number of leeches to be proportioned to the age and constitution of the patient, as well as the severity and duration of the disease. Emetics are very service- able in the first stage of this fever, in order to unload the stomach of any crudities it. may contain. It has been already stated, that laxa- tives frequently repeated are highly necessary: to an adult I give powders consisting of two grains of calomel, and six or eight of jalap or rhubarb, or a pill with the same quantity of calomel and four grains of the compound extract of colocynth. A child of six years old will require the same quantity of calomel, and four of jalap or rhubarb,— the dose to be repeated every second, third, or fourth hour, according to circumstances, till evacuations are produced, or till a fourth dose FEVER FROM INFLAMMATION. 157 has been given, when the medicine is to be assisted by the administra- tion of mild injections. Fomentations may also be applied to the ab- domen. If the body be hot, it should be spunged with cold or tepid water, as may be most agreeable to the patient's feelings. Opiates are rarely admissible in this form of fever. In neglected, or ill-treated cases of this class of fevers, affections of the brain, or bronchial membrane, are greatly to be dreaded. FEVER FROM INFLAMMATION. It will be recollected that, in a former part of the work, the arbi- trary doctrines of fever promulgated by different individuals, viz., that fever depended upon inflammation of one particular viscus or set of viscera, were rejected; and my own opinion was distinctly stated, that inflammation of every tissue of the body, occasionally gave rise to febrile disease. Symptoms of Inflammatory Fever.—In this disease the combi- nation of symptoms denominated fever is present, and depends upon inflammation of an acute or sub-acute nature, of some organ or tissue of the body. Cullen's definition: " Heat much increased; pulse fre- quent, strong, and hard; urine red; the animal functions but little dis- turbed." Although this fever sometimes takes place without any cold stage, yet it is generally ushered in with rigor. During the early stage, the patient feels drowsy, yet cannot sleep; he is reluctant to move from one room to another, from a feeling of languor and debility; there are loss of appetite, vitiated taste, thirst, loaded but moist tongue, which soon becomes dry; general soreness is complained of, and there are nausea and vomiting; headache, and pain in the back; occasionally a combination of all these symptoms is present. Sometimes after the first rigor, heat of skin, and all the other symptoms of fever, immediate- ly set in; on other occasions, there are alternate chills and flushes of heat for several days, till at last the heat predominates, and is permanent; the face is flushed, the skin intensely hot, with thirst, restlessness, ge- neral uneasiness; in most cases there is more or less delirium at night It is necessary to observe, that the symptoms vary according to the organ principally affected; but in all cases where there is great excite- ment, the breathing is quick and anxious, the belly costive; the tongue becomes parched, but it may be loaded, or very red, with its papillae much raised,—or intensely red only at the tip and round the edges; 158 FEVER FROM INFLAMMATION. the pulse is generally full, strong, and bounding, beating above 100, perhaps even 130 in the minute; there is also oppression at the prae- cordia. In very acute cases, I have observed the skin not only parch- ed and burning, but red, making a considerable approach towards an exanthematous affection. Inflammatory fevers occasionally terminate by hemorrhages from different parts of the body, particularly from the vessels of the nose and bowels; by diarrhoea,—collections of matter in various parts of the sub-cutaneous cellular membrane, and by profuse sweats. But these natural terminations are not to be depended upon. If the fever go on without proper treatment, disease of structure ultimately takes place, in severe cases as early as the seventh or eighth day; in slighter, not before the twelth or fifteenth; and in still slighter, not till between the twentieth and thirtieth. Whenever this event happens, all the symptoms of typhus gravior, with petechiae, &c. 6cc. take place, and then the case is called synochus. It has been stated that the symptoms vary not only according to the nature, but more particularly the seat of the disease; and it is necessary in this place to give a description of these, which may be made applicable to the other kinds of fever. There are several general symptoms which are common to a vast number and variety of diseases; as headache, heat and dryness of skin, thirst, nausea, restlessness, anxiety; oppression at the praecordia, dyspnoea, scanty urine, small fetid stools, &c.; but there are some symptoms which particularly announce disease of particular parts. If the head be affected with inflammation, the symptoms will vary according as the inflammation affects the membranes, or the substance of the brain itself.—If the membranes, there will in general be deliri- um, increase of strength, such that it will require some care to keep the patient from starting out of bed; the eyes vascular, with the pupils contracted or dilated, and the countenance may present a ferocious expression; the patient will perhaps complain of pain of head, by gesture if he cannot by words, the carotids will throb, there will be great restlessness. The face is not always flushed, it is sometimes pale; the pulse will be various, the tongue dry, and perhaps in con- stant motion. Subsequently starting of the tendons, picking of the bed-clothes, and sometimes convulsions, take place, particularly in young subjects; the patient shows a disposition to sleep, anjl then be- comes comatose, which state gradually increases, the pupils are dilated, and squinting often occurs. The respiration becomes more and more rapid and irregular, with an occasional interruption, immediately fol- Fi;VLR FROM INFLAMMATION. 159 lowed by a sigh; the pulse, which had been quick at first, and had afterwards become slower, is now again rising in frequency; it is irre- gular, and intermits. The coma becomes more profound, and death takes place with or without convulsions. If the substance of the brain be inflamed, the heat of skin may not be increased, the pulse may fall under the natural standard; perhaps it will beat 60 or 50, and I have seen it even slower. The extremi- ties may be in constant motion or not; they may be rigidly contracted, particularly the fore-arms, or if not so, they become contracted the moment the arm is touched even to feel the pulse. The rigidity may- be confined to one arm with or without paralysis; the pupils are ge- nerally dilated, and the eye-lids half or fully open, sometimes one is shut and the other open; the tongue is not dry till towards the last stage of the disease. In both varieties the respiration is much in the same state. The bowels are generally bound, and when stools are procured, they are passed involuntarily in bed, as is the urine; sometimes the bladder loses its power completely, and becomes greatly distended. If the lungs be affected, the respiration will become more laborious; there may be cough, with more or less expectoration; the patient may complain of a sensation of rawness under the sternum and in the wind- pipe, or perhaps a stich in the side may be felt; but here, as in all affections of the chest, we must make use of our ears in addition to the other symptoms, in order to discover whether any inflammatory affection is going on in the respiratory organs. The advantages of the grand discovery of ausculation will be stated more at large when treating of the diseases of the chest; but it may be mentioned, that even before I had been much used to the stethescope, I was able to point out "primary local affection'' to exist in the lungs, in cases which were supposed to present the pure idiopathic fever. If the seat of the inflammation be within the abdomen, it will in general be announced by one or more of the following symptoms,— pain increased on pressure; but it must be remarked, that when the mucous membrane of the intestines is the seat of the phlogosis, fre- quently little or no pain is experienced even upon pressure. The pa- tient will prefer that position in which the abdominal parietes are most relaxed: there is more or less tympanitis; and the heat is greater over that part of the body than any other. .Nausea and vomiting are more or less severe; the patient drinks large quantities of cold fluid, although he knows it will produce an increase of pain, and, perhaps, will be immediately vomited. The condition of the tongue, has, I fear, 160 FEVER FROM INFLAMMATION. been too much disregarded. The most extensive inflammation, and disorganizations of various kinds, may be going on in the mucous membrane of the stomach and bowels, without producing redness of the tongue or elevation of the papillae. Nevertheless, when the tongue is in that condition, or when it is covered with small ulcers, or when it looks red and glazed, or as if skinned, with or without patches of white fur, we are enabled to determine that the lining membrane of the alimentary canal is in a diseased condition. Appearances on Dissection.—It may safely be said that there is not an organ or tissue of the body which has not been seen disorgan- ized in fevers, and particularly in inflammatory fevers; and after what has been stated, and from circumstances which are still to be stated, it is thought unnecessary to dwell at present on this subject. Treatment of Inflammatory Fever.—Sydenham, whose works are among the greatest ornaments which medical literature possesses, recommended, above a hundred and sixty years ago, the same or nearly the same practice, which stands good in the present day. He was led by his great wisdom and experience into a proper line of treatment, although he had not the advantage which we enjoy, of examining morbid appearances after death, to confirm his views. He had erroneous notions, it is true, in consequence of his imperfect acquaintance with morbid anatomy, but he was the first who pointed out the impropriety of treating all fevers alike, by showing that dif- ferent organs are affected in different cases. He pointed out also very precisely, that a fever requires different treatment in every stage as it advances. He likewise made pointed observations against the farrago of medicines which were generally prescribed, and his own plans were exceedingly simple. It was he who first introduced the plan of purg- ing in fevers. His chief hope seems to have been on the lancet, laxa- tives, and opiates, the strict antiplogistic diet, and allowing no solid food. If he could have proved his opinions by an appeal to dissec- tions, it is probable there would not have since been so many changes in practice. An emetic, followed by gentle laxatives; a bland liquid diet; small doses of the solution of the tartrate of antimony; and perfect quiet- ness, will produce a cure in very slight cases. But in severe cases it is necessary to open a vein, and take away as much blood as will make an impression upon the disease, without reference to quantity. You no- practitioners are often prevented from using the lancet, because there is no decided fixed pain; but they may rest assured, that in fevers and more particularly in inflammatory fevers, some internal part in FEVER FROM INFLAMMATION. 161 fevers, and more particularly in inflammatory fevers, some internal part in particular is suffering, although it does not exactly appear to their inexperienced eyes. Local inflammation is often concealed by the general irritation and uneasiness which prevails; and it does not show itself to a superficial observer till it has become very severe. We must not bleed in the manner recommended by the French, at least in inflammatory fevers. Boisseau, urging the necessity of gene- ral bleeding, says, p. 99. of his work entitled Pyretologie Physiologi- que, Ed. 1824, " Less than 8 ounces should not be taken, at each operation; but this quantity will rarely suffice; it is necessary in general to draw 12 ounces; one may carry it even to 16 ounces, in subjects of whom I shall speak, but one never ought to exceed this quantity. It is better to repeat the bleeding." I would also beg to refer to the cases and dissections published by M. Andral, in the 1st vol. of his Clinique, in which the deplorable effects of similar undecided practice are too evident to require being pointed out. The causes of the failure of bleeding in this, and other diseases, are; first, most physicians order the precise quantity of twelve or sixteen ounces of blood to be taken from all adults, without reference to sex, age, peculiarities of constitution, or the actual pathology of the disease. Secondly, By the long period which is allowed to elapse between the bleedings, the strength is diminished, while little progress is made in eradicating the disease. Thirdly, No difference is in general made between bleeding a plethoric individual, and one who is in the oppo- site condition of system. Fourthly, The period of the disease influ- ences a pathological physician, while it does not one who never looks at the inside of a dead body. Fifthly, The good effects of a general bleeding are very frequently lost, by not following it up, in proper time, by a second evacuation; or by local bleedings, which are often found to be most efficacious. Sixthly, The good effects of bleeding are often marred by neglecting to employ counter-stimulation, and counter-irritation, as well as by loading the patient with too many bed-clothes, and by errors of diet. The patient should be seen within a few hours after the first bleed- ing, and the operation should be repeated at a short interval, if neces- sary. If this be done, particularly if followed by laxatives, blisters, and the use of the tartar emetic, it will rarely be necessary in an inflammatory fever, however acute, to bleed a third time. But if, at the second or third visit, we find the patient so well as not to require further loss of blood, we are not to conclude that he is out of danger; and it is necessary to impress upon the minds of students and young Vol. I.—21 162 CONGESTIVE FEVER. practitioners, that if they are to do good in such a case, the greatest attention must be paid at the very commencement of the disease: vigilance at this period will save much subsequent trouble and anxiety. When leeches are necessary, they should be applied as near the af- fected organ as possible. With regard to antimony, objections are very justly entertained against its use, when the stomach and bowels are either irritated or inflamed. Some practitioners do not allow their patients to use fluids freely, particularly cold drinks; but 1 believe this is a most injudicious pro- hibition, and that they may, in general, be allowed to gratify them- selves in this respect. The practitioner should be regular in his visits in all acute cases, as sick people watch the hours, and become impatient and dissatisfied till he makes his appearance; and he should be careful how he ex- presses himself; for one word, or even a slight alteration of counte- nance, may rob the patient of all hope. When the state of collapse comes on in fever, the patient should be carefully watched, that he may have his nourishment and medi- cines at proper intervals, and that the heat of the body may be pro- perly supported. Stimulants are frequently necessary at the termination of this class of fevers; but nothing'in the practice of medicine is more difficult than to determine, whether a stimulant given in such a case is to do harm or good. When it is given, let it be in small quantity, closely watch- ing the effect. If 1 were compelled to state, whether more mischief would follow the exhibition of stimulants in every case, or withhold- ing them, 1 could safely say, that giving them in every case would be highly prejudicial. For although I have seen marked benefit produ- ced by stimulants, yet I have more frequently observed mischief; they are most beneficial when exhibited to patients with either a compres- sible, or a very irritable pulse, and to those who experience profuse perspirations. CONGESTIVE FEVER. This is a fever, in the most severe form of which the pulse and the heat of the skin are generally below the natural standard. In sl^hter cases the extremities are cold, or have a tendency to be cold, while the heat of the trunk of the body is increased. The purest example of congestive disease, to which 1 can allude, is the epidemic cholera as CONGESTIVE FEVER. 163 it prevailed in India, and which has lately appeared in the east of Eu- rope; the next example is to be found in those individuals who die*in the cold stage of the yellow, or any other fever. The existence of congestion is also well displayed in the first stage of intermittent fever; and I have seen many cases of pure congestive fever succeed the cold stage of an intermittent, when full re-action could not de- velope itself as usual. Congestive fever is a very common complaint in this climate, and one which is usually treated as a typhus. It is a disease which Syden- ham knew well, and treated in the most judicious manner, as will be seen by consulting Swan's edition, p. 567. After stating that the in- vention of the term malignity, has been far more destructive to man- kind than that of gunpowder, he describes as decided a case of conges- tive fever, as is to be found in any modern work. " But if it be inferred (says Sydenham) that there is some malig- nity in the case, not only from the purple spots, but also from finding the symptoms of fever milder sometimes than should seem agreeable to its nature, whilst, notwithstanding, the patient is more debilitated than could be expected for the time, I answer that all those symptoms only proceed from Nature's being, in a manner, oppressed and overcome by the first attack of the disease, so as not to be able to raise regular symptoms adequate to the violence of the fever; all appearances being quite irregular. From the ani- mal economy being disordered, and in a manner destroyed, the fever is thereby depressed, which in the true natural order gener- ally rises high. I remember to have met with an instance of this kind, several years ago, in a young man I then attended; for though he seemed in a manner expiring, the outward parts felt so cool, that I could not persuade the attendants he had a fever, which could not disengage and show itself clearly because the vessels were so full as to obstruct the motion of the blood. However, I said that they would soon see the fever rise high enough upon bleeding him. Accordingly, after taking away a large quantity of blood, as violent a fever appeared as I ever met with, and did not go off till bleeding had been used three or four times." This case proves, beyond all doubt, that Sydenham must have had very good notions of the pathological condition of the body, from the expressions he uses, as well as from the practice he employed. This disease has been described by several tropical physicians, but particularly by Dr. Jackson; and it was in warm climates that I first obtained correct notions upon the subject But the profession is much 164 CONGESTIVE FEVER. indebted to the late Dr. Armstrong, for the very excellent manner in which he has illustrated its nature and treatment. Symptoms of Congestive Fever.—We shall find, upon inquiry, that the patient has had a threatening of indisposition for perhaps ten days, a fortnight, or even three weeks, previously to confining him- self,—that his appetite has been gradually impaired, with irregular action of the bowels; and that he has occasionally complained of alter- nate chills and flushes of heat, until at length the chilliness prevailed. This is the history which we in general receive of the progress of the severe cases. Even in mild cases, the heat of the skin is diminished; the pulse is weakened, or it is oppressed, and beats perhaps not more than 50 or 60; the prostration of strength is very considerable; the tongue is in general moist, and more or less loaded; the patient is lethargic, rather than comatose, though coma may subsequently take place; he can be roused, but the sensibility is evidently diminished; he com- plains of giddiness, confusion of intellect, heaviness, pain or sense of weight, either at the crown of the head or forehead. The general functions of the body will be found to be more or less impeded; but disturbance of some particular organ, in general, manifests itself, and the symptoms must of course be thereby considerably modified, as in other febrile diseases. In congestive fever, as well as in others, the brain may be the seat of disease in one person; the lungs in a second; the liver and mesenteric vessels in a third, and so on; the disease be- ing essentially the same, but modified according to the principal seat of the congestion. In congestive fevers there is generally a peculiar expression of countenance; it looks besotted; the manner of the patient is undecided, with an appearance of carelessness, and his words seem, as it were, to hang in his mouth; the cornea looks dim; the pupil, in the first stage, is rather dilated, and is not much affected by light. If the patient attempt to walk, he staggers like a drunken man. There is always more or less prostration of strength, and in severe cases, he is unable to stand upon his legs, or to move his hand to his head, even from the first. The respiration is short, quick, and weak. He often signifies that he has a great load in the precordial region. As the disease ad- vances, he becomes more and more comatose: picks the bed clothes; and is always found lying upon his back, slipping down by impercep- tible degrees to the foot of the bed; the surface becomes more cold; the breathing more difficult; the face assumes a leaden hue; and occa- sionally, though rarely, convulsions take place; sometimes there is nausea and vomiting, and sometimes diarrhoea; most frequently, how- ever, the patient is constipated. CONGESTIVE FEVER. 165 It may be shortly mentioned, that the appearances on dissection are much the same as those described in intermittent fever. With respect to the causes, they are the same as in other fevers; but I have seen several very severe cases produced by bathing in the sea, and remaining too long in the water; by taking a drink of cold water; and by a weakly person exposing himself to a damp, cold wind, when his body had been previously heated. Pathology of Congestive Fever.—No one can tell which is the first link in the chain of diseased action. Congestion may take place upon hearing disastrous news, which, some say, proves that a peculiar action in the brain is the first phenomenon; but, then, exactly the same circumstance may happen from taking a cold drink, or remain- ing too long in the water when bathing, &c. &c; therefore, it must be confessed there is a great deal of ambiguity about this part of the pa- thology. But it is unnecessary to go over the same observations which were made when treating of intermittent and other fevers, fur- ther than to state shortly, that when the head is the chief seat of con- gestion, there are early symptoms of lethargy, coma, and a diminution of sensibility, frequent chills, followed by other well-known nervous symptoms, and occasionally by convulsions. When the heart and lungs are loaded, there is an oppressed, irregular, or intermitting pulse; weak and hurried respiration; cough; marks of impeded cir- culation in the face, and a difficulty in supporting the heat of the body; and in some rare cases, violent pain in the region of the heart, and along the arms is complained of. It may be remarked, that whenever the pulse feels weaker than natural in a severe disease, it is an excel- lent plan to place the ear to the region of the heart, for we shall often find it acting most powerfully when the pulse is weak in the extremi- ties. When the congestion affects the viscera within the abdomen, there is generally a sense of fulness and distension about the stomach; the bowels arc irregular, being either too loose or bound; and in either case, when stools are procured, they are found to be clay-coloured and very fetid, with very little bile, or very dark. This opportunity may be seized for the purpose of noticing the most probable means which the animal system possesses, to prevent the balance of the circulation from being lost. First, there is a power possessed by all animals of preserving to a certain extent a proper de- gree of heat under every condition of atmospheric vicissitude,—thus the heat of the body is not a degree higher under a burning tropical sun than in this country, which so far prevents cold from producing a lost balance of the circulation. 166 CONGESTIVE FEVER. Secondly, The elasticity of the coats of both arteries and veins, tends also to prevent the state of congestion, because they are capable of considerable distension, and are still contractile. These are assisted by the free anastomosis which subsists between the vessels of a part This is well illustrated by the experiments which have been performed on the frog's foot to determine the nature of inflammation. When a part is first irritated, the momentum of the blood is greatly increased; at last a vessel becomes obstructed, a globule of blood cannot pass through it, but is seen to make a retrograde movement, and find its way by another branch. The pathology of this fever is happily illustrated by comparing the symptoms with the phenomena which occasionally take place in erup- tive fevers, and to which I shall now make only a short allusion. In some cases when the eruption is tardy in making its appearance, alarm- ing symptoms, and even convulsions, take place. After the eruption has made its appearance, it sometimes suddenly and prematurely dis- appears, when congestive symptoms occur. Let the inquirer ask him- self, where has the blood receded to, which a moment before rendered the skin as red as the shell of a boiled lobster? Treatment of Congestive Fever.—In considering this part of the subject, it is very useful to remember the efforts which are made by the powers inherent in the constitution to remove internal accumula- tions of blood, if they be in any way short of that degree which kills the patient instantly. The first of these, and the most common, is the state which in medical language is called re-action, which in its turn may create inflammation of the organ most affected with the congestion. We have next increased secretion, as a natural means of removing the congestion; as is well exemplified in the cholera-morbus of India, in which, for the most part, an immense discharge takes place from the intestines and stomach. In the treatment of all diseases, the physician has to determine whether it will be most advisable to leave the case to the natural ef- forts of the constitution, assisting them a little in their operations, or whether he is by a bold decisive measure to step ia to relieve the sys- tem at once. In this case, he is apprehensive that the heart and other vital organs may be too much overloaded and oppressed to create full re-action, or that the system will sink under the task. He has also to fear the efforts of the re-action, which may terminate in extensive local inflammation. Anxious to escape these evils, he will follow the plan pursued by Sydenham in the case quoted at page 119, and he will open a vein with a view of at once restoring the lost balance of the circula- CONGESTIVE FEVER. 167 tion. The quantity of blood necessary for this purpose, in any given case, cannot be previously estimated. A stimulant maybe at the same time necessary, to rouse the action of the heart a little, and make the blood flow from the orifice. I have frequently,proved, before a number of witnesses, that it is not inconsistent with good pathology to bleed and stimulate at the same time. When a vein is opened, the blood will perhaps only trickle down the arm at first; on other occasions it will spring from the orifice in a large stream, and suddenly stop before a table spoonful is evacuated. Some think this owing to an alteration in the position of the arm,— others, to the tightness or slackness of the bandage. < Physicians fre- quently attribute this phenomenon to debility, and they take it as the most certain sign that the patient will die in their hands, were they to carry the operation farther. But it must be recollected that the blood is moving very slowly in the arteries, while the veins are gorged. When an opening is made in the vein, it suddenly empties itself, and as a supply is not quickly at hand, it is some time before the blood begins again to flow. Let the finger be placed on the orifice, the vein will be filled, and the blood will spring again. Heat is also to be ap- plied, and if possible the patient should be placed in a'warm bath; if that cannot be obtained, the feet and legs should be plunged into very warm water, and hot bottles placed round the body. The patient is to be rubbed with stimulating fluids, such as heated spirits of turpentine, and aqua ammoniae; drachm doses of ether may be given, or a solution of the carbonate of ammoniae, in the proportion of eight or ten grains to an ounce of water. He should be encouraged to drink warm fluids. The caution and discrimination which ought to be pursued in drawing blood under such critical circumstances need not be insisted on;- suffice it to say, that a stimulant ought to be at hand and a finger should be on the pulse of the opposite arm, to watch the effects of our practice. If every thing go on well after the bleeding, the bowels being in a proper state, two grains of calomel and one of opium may be given in a pill, and repeated every three or four hours. General bleeding is only admissible in the earliest stage of conges- tive fever, unless in cases in which the pulse is still strong and full. Should the proper time for venesection have passed, stimulants are sometimes found serviceable, but must be administered with caution, and relinquished for perhaps debilitating remedies, upon the first ap- pearance of re-action. If, at any time in the subsequent progress of the case, there should appear signs of local disease, the application of leeches and blisters shpuld be had recourse to, and the patient is to be treated during convalescence in the same manner as in any other fever 168 TYPHUS AND SYNOCHUS FEVERS. TYPHUS AND SYNOCHUS FEVERS. In the disease which is now to be sketched, there is a combination of the last three described fevers, appearing under two forms: 1. The functional fever, subsequently united with congestion, and this forms, I apprehend, the Typhus of authors. 2. The inflammatory fever, subsequently united with congestion, and this is the Synochus of authors. The first variety begins in the manner which has been already de- scribed in fevers from functional derangement, but subsequently, an accumulation of blood takes place in the centre of the system. When the circulation becomes so much embarrassed, all the symptoms of congestive fever take place, the patient having been debilitated by the previous diseased action. The second variety commences in the manner which has also been already described in inflammatory fevers, but subsequently the balance of the circulation becomes more and more lost, and congestion fol- lows; in which state of the system the inflammatory action is sup- pressed, but riot extinguished. This takes place when debility and exhaustion have been already produced by the previous disease. The brain, lungs, and organs in the abdomen, are liable to be impli- cated, and in the worst cases which occur, they generally are all af- fected, either simultaneously or in succession. Hence there is a com- plication of symptoms, and as the disease principally affects the poor, who are ill clothed and badly fed, and as medical advice is not in ge- neral sought during the first stage of the disease, we usuallv find it very difficult to manage. In the early stage of the first variety, and when alone any thing like active practice should be had recourse to, the symptoms certainly denote debility, which are as yet occasioned by oppression and ob- structed action only; and often have I seen cases immediately and permanently benefited by drawing blood, in which, had the operation been postponed for twenty-four hours, it would have been quite inad- missible. It may likewise be remarked, that much of the oppression and debility also depends on the condition of the lungs, which, be- sides being congested and therefore unable to perform their functions properly, are subsequently still further embarrassed by an inflamma- tory affection of the bronchial tubes. Both these conditions tend to prevent the changes in the blood, which are well known to be elabo- rated in the lungs; therefore, all organs must suffer additionally, and TYPHUS AND SYNOCHUS FEVER. 169 the brain of course among others. The bronchitic affection in fever has attracted my attention for many years, and I am led to believe, that few instances of febrile affections take place, without bronchitis appearing in some stage of the disease, and very often it is the pri- mary affection. In all the fevers which are called putrid, and which are accompanied by dark-coloured spots on the surface of the body termed petechiae, it will be found, 1 am almost inclined to say invaria- bly, that bronchitis prevails to a great extent The somewhat livid and circumscribed redness which is seen so often in the fevers called typhoid, is principally owing to the embarrassed state of the lungs; and exactly the same circumstances take place in the second variety, the synochus. In the second variety, bleeding may be had recourse to with bene- fit, later in the disease than in the first, and often have I seen it deci- dedly beneficial when cases were going wrong under the injudicious use of stimulants and tonics. In proof of these statements, the reader is referred with confidence to Dr. Mason Good's account of typhus, in his second volume, (from page 230 to 258.) According to his views, this being "a disease of sensorial debility,leading on to putre- scency, is to be treated by tonics; bleeding and purging are among the foremost objects of prohibition." Nevertheless, in the next page, the following contradictory statement is advanced, " hence the fever will be aggravated from local irritation, and the affected organ will be in danger of inflammation, if not of gangrene." There is no class of diseases, in which the stethescope is of more practical advantage than in fever; for, as has been already mentioned, the heart may be found beating violently, whilst the pulse at the wrist is so weak as scarcely to be felt, and when symptoms of general de- bility appear to be very great, and the extremities cold. To a patient in such a state, most medical men would naturally be led to give wine, beef tea, and animal jellies, which they would not do if they were aware that the action of the heart was strong. During the-*last eight years, I have seen many severe cases of fever, in which marked benefit was produced by withdrawing stimulants, and the patients have ultimatelv recovered after being leeched and blistered. It has also occurred to me to be called in consultation to cases of "idiopathic" fever in which I have not only detected active disease, but have con- vinced the practitioners that it was going on. I shall never forget two cases of" idiopathic typhus," in which unfortunately my diagno- sis was verified by dissection, in one of which the patient died of Vol. I.—22 170 TYPHUS AND SYNOCHUS FEVER. pleuritis and bronchitis conjoined; in the other, of peritonitis. Let it not, however, be supposed that I am an enemy to stimulants in all cases of fever; on the contrary, I have seen patients occasionally snatched from the grave by their judicious employment. V\ hat is wished to be impressed upon my readers, is, that in all fevers we have to dread local congestions and inflammations, more than debility and putridity. That I am in the habit of using stimulants in fever, I can appeal to the gentlemen who have been my pupils, and who have witnessed my practice; and I can also appeal to them for the truth of the following statement:—that much mischief has occasionally fol- lowed, and that therefore I feel fully as anxious about the result of a stimulant as a bleeding. When a stimulant is necessary, wine is the best; and experience has taught me that wine, or any other stimulant, is far less likely to do harm than beef tea and animal jellies. Cases can no doubt be quoted, where stimulants, in large quantities, have been administered from the beginning of the disease, and the patients have recovered. But the best way for any one to come to right conclusions regarding this question, is, to judge from the general result of what he has himself seen. I have had many opportunities of observing that recoveries were slower, and relapses more frequent, in cases treated upon the stimulating plan, than the antiphlogistic. Emetics cannot be too highly extolled in the last stage of some cases of fever, particularly the varieties called typhus and synochus, but only in those in which the bronchial tubes become filled with muco-purulent matter. This happens in consequence of the patient being too long asleep, or not coughing up the matter before too much has been secreted. Many of my friends have seen the happy results of administering emetics in such cases, and more particularly, my dispensary pupils will not forget many instances of this among our poor patients during the late epidemic fever in Edinburgh. Cleanliness, free ventilation, and quietness, are three great and es- sential circumstances to be attended to in the treatment of fever. The alvine evacuations should be removed instantly out of the room; and it is of great consequence to attend that the quantity of bed-clothes be not too great in the first and second stages of fever when the skin is parched, or too small when the patient is approaching to the state of collapse. The extremities should be examined at every visit by .the physician, as sometimes the symptoms are aggravated in consequence of cold limbs, which will perhaps require no other remedv than the application of heat. The state of the bladder should be attended to; TYPHI'S AND SYNOCHUS FEVER. 171 for although the urine is generally suppressed, yet occasionally it is not so. The temperature of the room can scarcely be too cold in the first stages, but I have often seen much injury produced by keeping it too low in the stage of collapse. Many patients have been strik- ingly benefited in less than half an hour after their bodies were made warm, and perhaps their lives ultimately saved, without the assistance of any other means. Some owe their death to being removed from a warm and ill-ventilated room into the cold ward of an hospital; so frequently has this happened, that I am obliged to run all hazards from bad air, bad nursing, and filth, rather than send my patients to the Infirmary of Edinburgh, which is ill constructed for any class of patients whatever. The sick are also badly classified, which is per- haps no fault on the part of the medical attendants, who ought to be well aware that the temperature of a ward, calculated for fever cases in the first stage, is too cold for those in the last. Every fever ward of great extent should be warmed by means of heated air, and pro- vided with water-closets for the use of convalescents. For a considerable time it baffled me to account for the discrepant histories of fever which have been handed down to us, and for the confidence with which opposite practices have been recommended to our notice; but further experience has convinced me that this discord- ance of opinion may be accounted for by one or other of the following circumstances: 1st, A difference in the character of the prevailing epidemics, and the constitutions of the persons affected; for example, a functional fever will bear stimulating remedies which would kill a person labor- ing under an inflammatory fever, particularly if the inflammation affected a vital organ. A stimulant given in congestive fever may operate beneficially; whereas in functional fever, or in inflammatory fever, it would be very injurious. A well fed, and previously healthy soldier, who has no cares, will in general have a high-toned fever; whereas a poor, ill-fed, and badly clothed laboring man, worn out by cares and anxieties, and living in an ill-ventilated and filthy apartment, will be affected with one of an opposite character. 2d, An arbitrary and too often empirical practice, which has hitherto been too frequently followed. One physician always bleeds in every case of fever, another stimulates; and when the results are analysed, perhaps it will be found that the proportion of deaths is the same, and even these results will vary to support the one practice or the other according to the habits and constitutions of the patients; for instance, if our army and navy surgeons were to stimulate throughout 172 TYPHUS AND SYNOCHUS FEVER. the course of the fevers they have to deal with, they would scarcely save a patient; and if practitioners entrusted with the care of the sick poor were to bleed all their cases of fever, they would be quite as unsuccessful. 3d. Writers are too often guilty of an error which all medical men are liable to commit, viz. of mixing up opinions with matters of fact in their statements. 4th. The prevailing habit of drawing sweeping conclusions from one or two facts. 5th. Unphilosophical attempts to bolster up erroneous views by special pleadings. The proportion of deaths in fever, in my dispensary practice, from the beginning to the termination of the last severe epidemic in Edin- burgh, was as follows: Out of the first hundred and forty cases, there was only one death. This patient was anxiously attended by a highly respectable practi- tioner in this place, who was then my assistant; he died during a re- lapse after he had sat up. The proportion of deaths, however, sub- quently increased, so that in November (1827) the calculation of deaths was one in 37. This includes several individuals who were in the last stage before we were applied to; also a case of a girl who died during a relapse from accidental loss of blood after the application of leeches; an old Highlander, who would take no other medicine than his own mountain dew; and an old woman above 60, who, when con- valescent, took a shivering fit, died immediately. The appearances found on dissection, in our fatal cases, were as follows: In two cases there was well marked arachnitis, viz. by extensive effusion of coa^u- lable lymph, which was deposited between the arachnoid and dura mater. In both there was great vascular turgescence; some effusion into the ventricles; and in one of these there was white ramollisse- ment in the centre of the brain. In two men, and one old woman, the vessels of the head were found very much gorged with blood, and the pia mater, throughout its whole extent, had its vessels amazingly distended with dark blood. The preparations were dried on glass, and can even now be seen in this state. In these three last mentioned cases, there was some effusion under the arachnoid, and into the ven- tricles; and on slicing the brain, an unusual number of large bloody points were observed; there was also bronchitic efiusion, and in one of them a considerable portion of the lungs was in a state of soften- ing, and intensely red. In the old woman, there was little disease in the mucous membrane of the stomach and bowels; but in one of the [typhoid fever.] 173 men, there was extensive vascularity of this membrane, but no ulce- ration; the mucous membrane of the stomach was much corrugated; and the whole of the splenic extremity was studed with red points, which were seen through a great quantity of thick viscid mucus, which being washed off, and the stomach stretched, these red points were discovered to be vessels, which existed in immense numbers; the vascularity was greater, however, in the mucous membrane of the bowels, particularly throughout the whole of the ileum, and a great part of the colon. In the other man, when the abdomen was opened, the small intestines had a black appearance, as if in a state of morti- fication; they were found filled with a bloody-looking exudation, which, from its weight, had borne them down into the cavity of the pelvis. It was thought at first that this matter was the sole cause of the discolouration; but upon cutting open the intestine, it was found that they owed this colour principally to great vascularity; there were no ulcerations. There are dried preparations, and drawings of the appearances, in this case, in my museum. In other cases, there were ulcerations in the ileum and colon, of which also the preparations and drawings are in the museum; and I confess, I am inclined to believe, that if these appearances were properly looked for, they would be more frequently seen. In one case, the kidney was enlarged, as well as the ureter; the pelvis, on being cut open, was found to contain about six ounces of pus, and the inner membrane was very vascular. In the body of the old woman, who, it has been above stated, died sud- denly during convalescence, the chief diseased appearance was, that both lungs were found as black as they usually are when affected with melanosis. I was not at the dissection, being engaged at the time in delivering a lecture; but Dr. Crellin, who conducted the examination, sent for me, and it was proved to the satisfaction of all present, that this appearance was not melanotic, but produced by venous engorge- ment I had never before seen the whole of both lungs so complete- ly congested; they sank in water, but after being washed, they regain- ed not only their natural appearance, but their proper degree of bouy- ancy. The characters of the ulcerations shall be stated in the second part of the work, when treating of inflammation of the mucous mem- brane of the stomach and bowels. [Elaborate investigations, with regard to the phenomena of that form of continued fever, which resembles the typhus of camps, have been *nade by M. M. Louis and Chomel. The joint labours of these two distinguished pathologists have presented to the public a mass of facts, which greatly enrich the history of this prevalent febrile affec- 174 [typhoid fever.] tion. The term typhoid fever, is preferred by both these authors, as being most applicable to the protean shapes of the disease, and as reconciling the conflicting names under which it has hitherto been de- scribed. It has also the advantage of not originating in any precon- ceived idea, founded upon groups of symptoms which are merely in- cidental. Typhoid fever, according to the signification which is given to it, embraces a wide range, and includes many classes which hitherto have been considered distinct. Upon consulting the records of endemic and epidemic fevers assum- ing a form of typhus, the amount of minute detail, with regard to their exterior symptoms, will be found sufficient to convey accurate notions of the garb which they wore; but when we search for informa- tion, as to the extent, the precise nature, and the location of the ana- tomical lesions accompanying them, the descriptions will be found ex- ceedingly defective. An attempt has been made to fill this void, not by conducting observations upon a narrow scale, but by patiently waiting, until repeated recurrence of the same phenomenon, should place its existence, as an invariable attendant, beyond depute. The peculiarity of the labours of Louis and Chomel into the nature of typhoid fever, consists in drawing the intention of the profession to contain symptoms referrible to existing lesions, which had not been regarded as peculiar to this affection. From these they deduce a cor- rect diagnosis, established upon the sure basis of nature, and from the certainty which exists of an invariable diseased condition of particular organs, direct the attention to the danger of consequent destructive results. The prominent and material facts are all that we can now present, and these will be detailed as faithfully as it is possible in so cursory a review. The invasion of typhoid fever is not always the same, nor are the symptoms invariable. Precursory indications of the attack may exist, or they may be wanting. Most commonly the invasion is sudden and the transition from apparent health to disease is rapid. Of 112 cases, 73 were attacked suddenly, 39 laboured under premonitory symptoms. The phenomena of invasion were as intense in those who were warned of its approach as in those who were not. They were generally the following:—intense headache, sometimes preceded by diarrhoea; alteration of the features, stupidity, muscular weakness, ab- dominal pains, &c. Chomel has divided the march and progress of the disease into three periods, each including seven days, and characterized by particular manifestations, these are called septenary periods. [typhoid fever.] 175 Symptoms occurring during the first period. Headache in all cases, debility and stupor, diarrhoea, meteorism, increased sensibility of the abdomen, especially in the right iliac region, gurgling when pressure is made upon the lower part of the belly, epistaxis, and finally the eruption designated by the name typhoid eruption. Dur- ing the first period, the change of countenance is very striking; the features are without expression, and evince an indifference and apathy which is peculiar, and from which the patient can scarcely be roused. In consequence of great weakness, a position upon the back is main- tained, (decubitus sur le dos,) and if forced to sit upright, dizziness and vertigo compel him to resume the horizontal state. Insomnia is a frequent attendant, partaking of that form of disturbed rest which is called coma vigil. The mouth becomes sticky, its humidityvlimin- ishes, the saliva is thick and small in quantity, this is the first degree of dryness, afterwards becoming complete. The colour of the tongue is far from being as uniform as is stated, or of as much consequence as it has been considered. It is at the commencement red at the tip and edges, with a white film on each side; but for the most part, this reddening of the tongue does not present itself until the termination of the first period, and is preceded by a whitish suburral condition. The lips and teeth become dry and incrusted at the same time that the mouth is parched. Sore throat is not an unusual symptom. Loss of appetite, nausea, and vomiting are frequently noticed. Great thirst is a usual attendant. Diarrhoea is one of the most constant symptoms of this period, appearing in nearly every case; it may however be postponed to the commencement of the second. It differs as to the number of the evacuations and the character of the matter voided. Meteorism is owing to the presence of gas in the bowels, and in obscure cases can alone be detected by percussion; but at times the abdomen rises above the level of the thorax, and considerable uneasiness is the consequence. Gurgling noises are owing to the combined effect of gas and the liquid contents of the bowels, passing from portion to portion, favoured by the peculiar condition of the ileo-coecal valve. At the commencement the general reaction is high, with well- marked inflammatory symptoms, but these in a few days diminish, the pulse retains its frequency, but loses its fulness and force, becoming small and weak. The skin is acridly hot, and frequently continues so during the disease. The heat is in the first instance accompanied with moisture, but soon becomes dry and mordicant Epistaxis is an important circumstance, and its frequent occurrence is peculiar to 176 [typhoid fever.] this affection. The respiration is affected with the sibilant rale; there is cough, and expectoration of transparent, viscid, tenacious mucus. The last phenomenon we shall mention is the typhoid eruption. Of 54 cases in 1831-32, but two presented this symptom as early as the sixth day; in the remainder it was witnessed during the second and third periods. Death is rare within this first term: it happened once in 42 fatal cases. Symptoms of the second period.—At this time we have new symp- toms submitted to our inspection, and modifications of those which already exist. Generally upon the seventh or ninth day, the typhoid eruption makes its appearance. This consists of small rose-coloured spots from half a line to two lines in diameter, of a rounded or oval form, scarcely elevated above the skin, and which are readily removed by pressure, but return immediately when it is withdrawn. These spots are scattered over the abdomen, sometimes upon the chest, and rarely upon the thighs, arms, and other parts. To characterize typhoid fever, the number of them should at least amount to five and twenty. Their continuance is by no means uniform, disappearing in two or three days, or remaining twelve or fifteen. When they are about to disappear their colour becomes less intense, and finally fades away entirely. No conical form or vesicular condition is ever apparent. Of 70 cases, 16 were without them. The time of appearance may, however, be late in the progress of the disease, it has been observed as late as the 39th day. Another eruption is witnessed during this period, characterized by the form of vesicles called sudamina. They are minute, elevated and transparent, and can be more readily perceived upon viewing them obliquely. There exists a remarkable disposition to the formation of sloughs and the production of foul sores upon different portions of the body, especially where pressure is kept up, or irritating substances have been applied. Ulceration, however, is not confined to the ex- ternal parts, but is observed in the mouth, throat and on the tongue and lips. Leech bites and minute incisions may exhibit the same tendency to ulceration, but this circumstance is rare. It is at this time that previous stupor and prostration become more marked, occasioning perfect helplessness,Band involuntary discharges from the bladder and bowels. Finally, difficulty of deglutition, consequent upon organic change in the structure of the throat, or upon weakne>s, .>pas- modic action of the muscles of the face and extremities, or complete rigidity of them; delirium, increase of meteorism and diarrhua, bloody alvine discharges, together with great fetor of the perspiration and [typhoid fever.} 177 pulmonary exhalations, are the most essential symptoms of this second period. Symptoms of the third period.—The phenomena of this period vary according to the change which may be undergone, whether to a safe state of convalesence, or to a still more alarming condition, shortly terminating in death. If the former event is about to happen, all the symptoms are gradually ameliorated. But should the contrary termination threaten, symptoms indicating the near approach of disso- lution will be apparent. The stupor becomes profound, the mouth secretes a greyish, sanious, fetid discharge. The urine has an unna- tural, disagreeable smell. Respiration is more and more embarrassed; the pulse is small, weak, and fluttering; the skin becomes cold and clammy, and the countenance has that peculiar expression which is designated fades hippocratica. In this condition the patient dies, or convulsions may precede the concluding scene. Of forty-two cases which terminated fatally, ten died during the two former periods; the remainder, after the third had been entered. Anatomical lesions.—There are particular organic changes which are almost constantly observed in this disease, an exception rarely occurring; but there are others, found in different organs, which are not so invariable, whose frequent absence evince that they do not constitute a portion of the affection, and which may be regarded as accidental. Under this impression, the anatomical lesions may be separated into two classes, constant and inconstant. The first occu- pies the mucous follicles of the intestines and the mesenteric gan- glia. The follicles are of two kinds, isolated and clustered: their mode of alteration and appearance is by no means the same under all circumstances, but varies according to the period of the dis- ease arid the form which it may assume. It is a difficult matter to determine when alteration of the follicles commences, as death never happens prior to the seventh day. Of 5") subjects inspected by M. Louis, the earliest period at which death took place was the Sth day. When under these circumstances an incision is made into the abdo- men, the intestines are noticed distended with gas, which augments their transparency, and permits us to distinguish exteriorly numerous opaque spots, corresponding to the diseased follicles. Examining into the nature of the change in these, they will be found prominent, and swollen, and from having their edges brought into relief, present somewhat the form of mushrooms. Their colour varies in intensity, but is always more or less marked, exceeding that of the surrounding mucous coat. Their size and form retain as little uniformity as their Vol. 1.—23 178 [typhoid fever.] colour: the largest are eliptical, exceeding in rare instances two or three inches in length, and half or a whole inch in breadth; they occupy the glands of Peyer: the smaller ones are round, and have their seat in the same glands; but besides these, there exist isolated and scattered prominent follicles, rounded and swollen; the latter are the glands of Brunner. The usual location of these appearances is upon the side of the gut opposite the mesenteric attachment, and they are more numerous, dense and larger near the valve. The plates (placques) give to the feel a sensation as if a solid, elastic substance was intro- duced between the intestinal tunics. Upon the seventh day, in a single case, and at periods not long after in other cases, the mucous membrane covering them had undergone no appreciable change; if any thing, its thickness was rather diminished than increased. If the glands are cut into perpendicularly, the mucous membrane is first divided; then a layer of yellowish-white matter, homogeneous in con- sistence, firm and brittle, the cut surfaces being smooth and shining: the thickness of this matter varies from one to two lines; beneath is found the cellular tunic. An orifice is rarely noticed in the clustered follicles, but is readily detected in the isolated. At this stage the mesenteric ganglia situated between the lamina of this attachment, which are nearest to the diseased follicles, are in- creased in size and become red. They are even observed as large as a pigeon's egg. There is sometimes complete softening of them, while at others, their firmness is rendered greater. These are the most important lesions, but in their development an uniform state of progression is observed. Ordinarily those nearest the ileo-coecal valve are the first to become affected: and, in the early stages, as they recede from this focus, a greater degree of healthiness is noticed: but as the disease advances a greater number is brought into deranged action. The same circumstance holds both with regard to the follicles and the ganglia. Sometimes several feet of intestine are implicated in this manner. Later in the disease, other conditions are perceived: the mucous membrane investing the follicles becomes rugose, hol- lowed out, and disappears entirely, leaving an excavation which pene- trates more or less deeply into the subjacent layer; but as this latter is not entirely removed, there remains a portion of the gland to show the progress of the alteration. According to the combined observa- tions of Louis and Chomel, it was determined that ulceration com- mences from the eighth to the fifteenth day. Ulceration pursues the same course as tumefaction, beginning at the same location, and is more frequently observed in the glands of Peyer. The aspect of the [typhoid fever.] 179 ulceration presents two varieties: in one, it commences in the mucous membrane, originating at a minute point and extending until the whole gland is involved: in the other the ulceration begins with soften- ing of the yellowish matter, and a process is gone through resembling gangrene, by which the whole substance is removed; the remains are evident on inspection, but diminished by suppuration, while the in- vesting mucous coat is in a comparatively healthy condition, or only partially displaced. This latter variety is more frequently met with in the clustered follicles. Fully formed ulcers assume conditions which it is important to notice: their edge or bottom presents no remains of the substance of the follicle in a partially broken down state; it has entirely disappeared, leaving a vacuity in the mucous membrane. The form of the ulcers is various: some are elliptic, others are round: they are also as dissimilar in size, and in some cases the borders are so smooth as to convey the idea of their production by a punch. In some, the mucous membrane alone has been removed, the bottom of the ulcer consisting of cellular tissue; but in others the cellular and muscular layers of the gut are likewise deficient, the exterior peritoneal coat preventing complete perforation. During the first and second periods, it is rare that the ulcers are as numerous as the prominent follicles. Opportunities are sometimes afforded of witnessing the mode of healing which these ulcers take on. It is in precisely the same way that ulceration of the skin undergoes the process of cure: minute granulations sprout up, and are converted into the reticulated tissue which forms a true cicatrix. Cicatrization, after it has been completed, is plainly demonstrable; but after a length of time becomes con- founded with the untouched mucous structure, and no trace of it is to be detected. Corresponding to the advanced change in the follicles, is a condition of the ganglia closely allied to suppuration, and in some cases pus is found in their substance. Lesions of organs inconstant as to their presence or absence, appear at times as accidental accompaniments of the pathological conditions which have been somewhat minutely described. They are, ulceration of the mouth, tongue, pharynx and oesophagus,—injection, softening, alteration of the relative thickness of the mucous coat of the stomachj very rarelv ulceration; similar changes in the intestines; alteration of the size, consistence and colour of the spleen; and less frequently of the liver; varied conditions of the pulmonary apparatus are occasionally present, for the most part the consequences of inflammation. And lastly, deranged structural conditions of the brain and its appendages. 180 [typhoid fever.] A few words with regard to the diagnosis, the nature of the affec- tion, and one or two interesting facts connected with the peculiar ana- tomical lesions, will conclude this very brief account of the researches of Louis and Chomel. At the immediate onset of the disease it is extremely difficult to determine the character which will be assumed, and some time will elapse before sufficient definite marks are detected, to warrant an opinion. Nevertheless, even during the first few days, a pretty correct conjecture may be entertained, from the occurrence of several attendant circumstances. Thus, if the attack be sudden—if, from the first, persistent headache be established, with giddiness and tottering in the gait, combined with well developed fever, suspicion will be aroused; but if still further, upon the second or third day, there exist diarrhoea, prostration, commencing stupor and nasal hemorrhage, this suspicion will be almost converted into certaint}\ But it is most prudent to suspend our decision until more fully determined symp- toms are presented; and these are meteorism, typhoid,rosaceous erup- tion, low muttering delirium, sudamina, fulginous aspect of the mu- cous openings, &c, which, combined with the preceding, will remove all doubt and obscurity. A question presents itself, how far the disease termed typhoid fever is connected with the lesions which have been described. To deter- mine this, it will be proper again to recur to the division which was made of the anatomical derangements into two classes, constant and oc- casional. Now it being conceded that the latter are but accidental, im- portant truly as complications, but not necessary to the existence of the disease, the constant lesions will constitute the objects of our inquiry. Are they so uniformly present in all cases as to warrant the appella- tion constant? In all but a very few rare instances they have been found. These instances have occurred in the hands of such able observ- ers as Andral and Louis; and,it may still be regarded as undecided whether they were true forms of typhoid fever, or depended upon circumstances which were wholly independent of it. As to the se- condary or primary nature of the lesions, a great deal could be said. The intensity of the symptoms, however, bears no proportion to the number of diseased follicles, in as much as numerous cases occur where these are deranged but to a small extent: in two cases, but a single ulcer could be detected. M. Chomel is inclined to the idea that in this respect the affection is allied to the exanthemata. A remarkable termination sometimes happens in this affection: it is the sudden and unexpected occurrence of peritonitis, which fre- quently succeeds the exhibition of cathartics; the cause of its pro- HECTIC FEVER. 181 duction is dependant upon intestinal perforation, and consequent escape of the liquid contents of the bowels into the abdominal cavity; such an event is almost necessarily fatal, and little hope can be enter- tained of the life of the individual.] HECTIC FEVER. Hectic fever is generally supposed to be symptomatic; even Cul- len embraced this opinion. It may be defined to be febrile symptoms occurring in the course of some internal chronic disease, when the patient is much debilitated. Heberden states that irritation in any diseased organ will give rise to it. An opinion has been pretty gene- ral, that hectic fever is produced by no other cause than the absorp- tion of pus; and when pus was not found upon dissection, it was hast- ily concluded that it had existed, but was all absorbed; or that hectic fever is sometimes idiopathic. My own belief is, that this combina- tion of symptoms has no necessary connexion whatever with pus; and according to my experience, it most frequently (although certainly not always) depends on inflammation of the mucous membranes, and more particularly that of the stomach and bowels. Symptoms.—Hectic fever is attended with great and increasing debility; a weak quick pulse; each paroxysm commences with chilli- ness, succeeded by re-action, and which is soon followed by copious perspiration. Indeed, sweating is at all times easily excited by any exertion. The surface is pale, except the cheeks, which present what is very aptly styled the " hectic blush;" and there is frequently great wasting of the muscles. The appetite is impaired, the stomach occa- sionally very irritable, and in nine fatal cases out of ten, diarrhoea comes on during the course of the disease. The discharge from the bowels is always very fetid. The breathing is anxious. The patient is generally restless, and frequently complains of pains that are as- cribed to rheumatism. It is said that this disease is liable to be confounded with intermit- tent fever; but the history of the case, and the appearance of the patient, will readily distinguish them. Treatment.—As hectic fever depends upon a morbid condition of some structure of the body, our attention must be directed to the seat of the disease. Surgeons very often cure patients of hectic fever, by cutting off a diseased limb which had produced the constitutional symptoms. There is no case in which the difference is so strikingly 182 GENERAL PATHOLOGY OF shown between routine practice, and that which is directed by sound pathological views. The routine practitioner will be invariably found to treat some of the symptoms thus:—Has the patient no appetite? Give him a tonic.—Is he purged? Prescribe an astringent.—Is he griped? Give him an opiate.—Is the urine scanty? He must have a diuretic.—Has he profuse perspirations? Let acid drops be ex- hibited!* A pathologist, it must be admitted, is often obliged, in the present state of our knowledge, to act empirically; but his remedies will always be found to be few in number. If the patient have diarrhoea, he will endeavour to ascertain upon what morbid state that symptom depends; if there be pain in the abdomen previous to an evacuation, if the pain be increased by taking a cold drink, if the tongue be red and glazed, if there be apthous ulcers in the mouth and throat, if the stools are mixed with mucus, or are watery and fetid, he knows he has to treat inflammation, and probably ulceration of the intestines. This leads him to apply a few leeches to the abdomen, if the patient's strength be not greatly reduced, followed by counter-irritation; and then, if there be any remedy that he knows will relieve the patient, that remedy he will prescribe. It is truly lamentable to see the symp- tomatical physician, one day treating the diarrhoea with astringents, and the next waging war against the perspirations.—This subject will be more fully illustrated hereafter. Opiates are frequently of con- siderable use in soothing the patient's sufferings. GENERAL PATHOLOGY OF ERUPTIVE FEVERS. The diseases which fall to be described under this head, are to be considered as fevers attended, during part of their course, by eruptions. Whatever difference there may be in the appearance and form of the eruption, they have a certain general character common to all, viz., that febrile symptoms precede the eruption. According to the humoural pathology, the fever is produced by a concoction of the humours, by which a peccant matter is thrown to [*Yetitmust in candour be confessed, that there are numerous modifications of disease in which we can do little else than palliate symptoms. Thus every prac- titioner must have met with examples in which life has been prolonged, and suf- fering mitigated, by checking a diarrhoea, or a colliquative perspiration, by direct and what might be called empirical remedies. These observations will .be prac- tically applied in the chapter on Phthisis.—Ed.] ERUPTIVE FEVERS. 183 the surface, forming the eruption. Other pathologists look upon these diseases as peculiar and essential affections of the epidermis, some- times followed by inflammation of the chest and its accompanying fever; and they account for the sore throat which occasionally occurs, by its continuity between the skin and the diseased internal organs. My own opinion is, that the eruption ought to be regarded as a mere symptom of this class dff disease. Yet it cannot be denied that there is something very peculiar in it,—peculiar, in as much as the eruptions present external characters differing from each other, as well as from other eruptions, and that the diseases occur only once in a lifetime. After a long and patient investigation, comparing the symptoms with the appearances found on dissection, I have come to the opinion, that the mucous membranes are the seat of the disease, the nature of which is inflammation, more or less acute and extensive; and that the part generally most implicated, is the mucous membrane of the lungs, particularly in measles and small-pox; while that of the bowels is the part chiefly, if not principally, affected in urticaria, roseola, and miliary fever. The eruption is merely to be regarded as a symptom, and by no means a universal symptom. It is well known that many cases of eruptive fevers are very mild, and require little treatment, while others are.extrcmely severe and fatal; and that a great deal depends upon the eruption, whether it comes out at the usual period, and whether it remains out, or prematurely and suddenly recedes. The eruption, in point of fact, ought to be regarded as a natural blister, acting as a counter-irritant. It is produced by powers inherent in the constitution, that enable it to remove so much of the diseased action from an internal organ, the functions of which arc more immediately necessary to life. In slight cases, I conceive the eruption is in proportion to, if it do not exceed, the amount of the internal disease. This may be stated without reference to the quan- tity of the eruption, except perhaps in small-pox. There can be no doubt that the eruptions are produced by inflammation of the cutis, which consequently must take off so much of the determination of blood, and so much of the diseased action from internal organs. These circumstances it appears to me, are clearly proved, 1. By attending to the constitutional commotion and oppression of the whole system, and the morbid changes in the functions of various organs, for many days before the appearance of the eruption. 2. By the relief afforded, in general, after the free developement of the eruption. :i. By the increased suffering and danger which exist when the 184 GENERAL PATHOLOGY OF eruption is deficient, or when its repulsion suddenly and prematurely takes place. 4. By the relief which follows proper treatment; and, 5. By the appearances observed on dissection. With respect to the first of these points, it may be stated, that the eruption does not appear in general till the third, fourth, or fifth day of the complaint, and during that time, the patient1 labours under the cbmbination of symptoms denominated fever, and suffers from the impeded functions of all organs; all the symptoms denote internal disease. That the respiratory organs suffer very considerably, may be discovered by the state of the respiration, the cough, the anxiety and colour of the countenance; but more particularly by auscultation, which will announce bronchitis in its first stage. In this stage, which is called the eruptive, there are very frequently affections of the brain, announced by the patient being in delirium, lethargy, or even coma; and it is by no means uncommon to see convulsions, or other serious nervous symptoms come on, at the period when the eruption ought to have been fully developed, but has not yet appeared, or has only partially come out. As to the second point which has been offered in proof, it is to be observed, that the symptomatical physician will not be inclined to re- ceive it as evidence in favour of the views which I wish to establish. He will say there is no relief; and in so far he will say truly. The eruption being occasioned by extensive inflammation of the skin, pro- duces great irritation, and very often an increase of the febrile symp- toms; that is to say, the person will complain more of thirst, restless- ness, and uneasiness, than previously. But still a pathological eye will discover relief,—relief produced by the translation of a part, and perhaps a great part, of the diseased action from internal organs to the surface. The symptomatical physician will point out to us that the respiration is still hurried and short; but we may be able, after an ex- amination of the lungs, to assure him that there is less congestion of the lungs, and less inflammatory action in their mucous membrane, than before; and that the state of the respiration which he has noticed, is now produced principally by the hurried circulation through the lungs; so that pathologically speaking, the patient is relieved. A com- mon blister, when it is sufficiently large, very frequently increases the patient's sufferings, while it has mitigated the disease. The third point of proof is the acknowledged danger which exists when the eruption is deficient, or when its repulsion has taken place. ERUPTIVE FEVER. 185 Dr. Gregory, in his lectures, when treating of scarlatina, used to make the following statement: " We find a connexion similar to that be- tween the efflorescence and other svmptoms in this disease, existing between the eruption and general affection in measels, for there it is not critical, but is accompanied with an alleviation of the symptoms, which is greater or less according to the degree of. the eruption; and all the symptoms are very much aggravated by the repulsion of it." Indeed, if the reader will refer to any author who has written upon this subject, he will find, that in the severe forms of the disease, which are commonly described under the terms scarlatina maligna, scarlatina an- ginosa, and in rubeola putrida also, the eruption is either wanting, or it appears at irregular periods, but is seldom permanent: and it is in these" severe cases that we meet with what are called typhoid symptoms, diar- rhoea, and haemorrhage from the nose, mouth, or bowels. The first ques- tion which it is natural for an inquirer to ask, is, by what cause is the danger produced? It appears to me, that the reply is very easily made. There has been lately an extensive inflammatory action in the skin, which required a determination of blood to support it. During this time the symptoms were not very severe; but the moment that the blood forsook the surface, it was marked by increased internal distress; the respiration became more laborious, and the patient more or less comatose; perhaps convulsions appeared. Is it not quite natural, therefore, to conclude, that these effects are produced,by the sudden determination of blood taking place towards internal parts, ending in inflammation of one or more organs, if the eruption be not brought back? But it will frequently be that kind of inflammation which has been described as " suppressed," and which cannot fully devclope it- self. The external symptoms will lead a symptomatical physician to stimulate and give tonics, when the pathologist would try the effect of the warm bath, stimulating frictions, and bleeding by leeches, if he could not open a vein; and he would also apply blisters. The fourth point in the evidence is the relief afforded by proper treatment. When the eruption is repelled from the surface, we use all the means within our power to recall it; the warm bath and stimu- lating frictions are first employed. The warm bath, which is the principal means to be depended on, may not be at hand, or we may have 'tried these remedies and failed; but we ought not to delay long under any circumstances, to open a vein, if the eruption be not speed- ily re-produced, particularly if the patient be above two years of age, and a vein can be found; if not we niu>t depend upon leeches, warm bath, and blisters. By opening a vein, however, we prevent a great Vol. I.—iM 186 GENERAL PATHOLGY OF deal of mischief and risk to the patient. If we cannot recall the blood to the surface, we reduce the quantity of it in the whole system, and thereby remove the congestion from internal organs, alter the de- termination of blood, and then assist the system in creating re-action, if necessary, by the addition of a stimulant. But all this, to produce benefit, must be done instantly; every moment lost, diminishes the chance of success. I am entitled to speak strongly, from the great success which has attended the treatment here recommended, not only in my own practice, but also in that of many of my pupils. Although many of these cases may be quoted in detail, yet the perusal of the following case, translated from the Clinique Medicale, by 31. Andral, » vol. iii. p. 72, will perhaps make a sufficient impression upon the minds of my readers. This case is entitled, " Acute bronchitis; Measles; Premature disappearance of the eruption; Fatal dyspnoea." " A baker, aet. 20, of a strong constitution, was affected within the last five or six weeks with slight diarrhoea; presented on the tenth April all the precursory symptoms of measles, redness of eyes, flow of tears, coryza, hoarseness, cough; and continued in this state for the three following days. On the 14th the eruption appeared, and the patient took to his bed. On the 15th his whole body was covered, and in the evening he was admitted into La Charite; when he had a con- fluent, well-marked eruption; hardness and quickness of the pulse; red- ness of the tongue and lips; and a strong cough; there was otherwise no alarming symptom. Towards the middle of the night, the patient experienced, all of a sudden, an oppression, which rapidly increased, and on the following morning we found him in a state of partial as- phyxia; the eyes prominent; the face violet colour; respiration short and very frequent; cough nearly constant; little mucous expectora- tion. Percussion elicited the natural sound through the whole of the chest, but the mucous rattle was audible, in different points, by means of the stethescope. There remained only a few pale spots of the cutaneous eruption, which were fast dying away. The pulse preserved its frequency and hardness, and the tongue its redness. This train of symptoms seemed to indicate the existence of pneumonia; nevertheless, the pathognomic signs of this complaint were completely wanting. "Could a simple bronchitis occasion, by its extreme acuteness or sudden exasperation, so much dyspnoea? and might not this inflamma- tion, joined to that of the alimentary canal, account for the complaint with which the patient had been so violently attacked? Be this as it may, the indications of treatment were clear; to lessen the internal ERUPTIVE FEVER. 187 inflammation,* and to effect a return of that on the skin. With this object, twenty leeches were applied to each side of the chest, and ten to the epigastrium. After the blood had ceased flowing, a blister was applied to each leg, and the skin rubbed all over with liniment of ammonia. Marked relief followed the use of these means; in the even- ing the respiration was much less impeded, the cough less frequent, and the tongue had lost its redness. The eruption, however, had not returned. 17th, The patient presented the symptoms of a severe bronchitis, accompanied with fever; the respiration was only slightly accelerated. 18th, The fever was reduced to almost nothing, and the opaque expectoration announced the speedy termination of the bronchitis. In the evening, the respiration suddenly became very difficult, and twelve ounces of bloodt were abstracted from the arm. The next morning the dyspnoea was still very considerable, and the pulse had become more quick. Two blisters to the thighs. During the whole of the day, the sense of suffocation continued to increase. "20th, Face extremely livid, violet colour of the lips, orthopnoea; from the appearance of the patient, one would have thought that he was dying of aneurism of the heart. " Jnspectio cadaveris.—The mucous membrane of the larynx, trachea, and bronchial tubes, and of the smaller ramifications, were of a scarlet red. In a few points at the beginning of the division of the bronchia, there were some white concretions, resembling the false membrane found in croup. "The lungs were sound and crepitated throughout their whole ex- tent; posteriorly they were gorged with blood. Heart natural: clots of blood of a deep black in the right cavities; stomach white, as well as the small intestines, which contained a great number of ascarides and lumbrici in the lower portion; the caecum contained several worms, (triocephales;) its mucous membrane presented a red spot near the valve, from which arose three or four small conical vegetations, three or four lines long. The rest of the large intestine white, and filled with liquid feces. Liver gorged with blood. Spleen large and firm. A great quantity of serum infiltrated into the sub-arachnoid cellular tissue; the cerebral substance was not at all injected; the * Had the distinguished author used the term "congestion" instead of inflam- mation, and had he employed venesection without delay, instead of applying leeches, he would have altered the determination of blood, and probably relieved the deceased organs. | It is to be regretted that this was not done two days earlier. 188 GENERAL PATHOLOGY, &C. lateral ventricles, especially the right, were distended by much limpid serum." The fifth point of evidence rests upon the appearances found on dissection; and it may be shortly mentioned here, that these consist of all kinds of lesions of the brain and membranes usually produced by acute and sub-acute inflammation. The same observation may be made respecting the organs in the thorax. Within the abdomen, the chief diseased appearance to be observed is in the mucous membrane, particularly of the large intestine, which is inflamed, sometimes ulcer- ated. But in no case does the pulmonary system escape. The appear- ance of the brain and abdomen are not so universal, and may occa- sionally depend upon the impedAl functions of the lungs, as will be shown hereafter. If these observations be not fallacious, bleeding to a sufficient extent ought not only to relieve the constitutional symptoms during the eruptive fever, but after the eruption has appeared, ought to destroy it. Observations and experiments frequently performed and repeated by myself, and by my pupils, enable me to state, that these are facts, which 1 shall not be afraid to repeat before the highest authorities in the profession, and stake my professional reputation upon the general result of the plan; having already seen recoveries take place, under this treatment, in cases in which such a happy termination was scarcely to be anticipated. It also follows, if these thing sbe true, that even in ordinary cases there are two periods, more critical and dangerous to the patient than any other; these are, the period at which the eruption ougjit to make its appearance; and that at which it should naturally disappear. In the first case the internal disease has gradually become extensive and severe, and wants relief by means of the eruption. In the second, the disease which had existed at first, having been relieved by the external irritation, is now in danger of being re-produced by its ces- sation ; and this of all others is the period at which, in the slightest form of the disease, the patient stands most in need of care and vigilant at- tention to the condition of internal organs. This pathological description, if it should appear deficient, is so only, I am convinced, from the want of sufficient illustration, which would, require a separate treatise on the subject. It is introduced in this place to prevent repetition, when treating of each of the diseases which fall now to be described. SCARLET FEVER. 189 SCARLET FEVER. This term is employed to denote a disease attended by a fever, sore throat, and a red rash on the surface, which rash appears sometime between the second and fifth or sixth days of the disease, first upon the face and neck, and progressively spreads over the body, terminat- ing between the seventh and tenth days. The rash has very much the appearance of the shell of a boiled lobster, and frequently there are minute vesicles. The inflammation of the throat sometimes runs into ulceration and sloughing. The literary history of this, or of any other disease, is of little im- portance in comparison to an intimate acquaintance with its pathology, and proper means of treatment. Therefore I shall proceed to de- scribe the phenomena, without caring from whence the disease came, or in what century it first appeared, further than to notice that scar- latina and measles were formerly confounded, from their mutual patho- logical resemblance. Sydenham appears to have been the first who gave this disease the name of scarlet fever, as well as a distinct de- scription of the affection, pointing out the circumstances, with suffi- cient precision, in which it differs from measles. The term scarlatina, notwithstanding the philippic of Dr. Mason Good, is quite as good as his term "rosalia;" it affords us an example of what is by no means rare, a disease receiving its name from a sin- gle symptom. Scarlatina has been divided into three species, viz. Scarlatina simplex. ---------anginosa. ---------maligna, which last includes the disease termed cynanche maligna. My chief objection to these terms is, that they do not spring from pathological considerations; and it may be said in the language of Dr. Hamilton, sen., (not the professor,) that " it is altogether foreign to my purpose to engage in this controversy; and more so, as the distinction begins to lose ground as our knowledge of the disease becomes more comprehensive and accurate. The time may not be far distant, when scarlatina will be received as the generic disease, the full history of which will include the more aggravated symptoms as they appear in scarlatina anginosa, and in cynanche maligna; in the same manner as the history of variola comprehends the varieties of the distinct and confluent small-pox." 190 SCARLET FEVER. Symptoms.—In eruptive, as well as other fevers, there are two great varieties, which may be named the congestive and the inflam- matory; and sub-divisions might be made of different combinations of these two. In the congestive form of scarlatina, the patient complains of op- pression, and so much debility, that he cannot support himself. Rigors more or less severe accompany, or precede, these symptoms. The face is pale, the features sharp, the eyes hollow, and deprived of their accustomed animation; the surface cool, particularly the extremities, while perhaps considerable heat is felt on the trunk of the body; the breathing is performed with more or less difficulty; the pulse varies, being sometimes soft, and perhaps weak, although it is occasionally strong; the tongue has a whitish and shrunk appearance. If the patient utter complaint, it will be of universal prostration and of head- ache, or weight on the top of the head, together with oppression at the praecordia, and difficulty in swallowing. On examining the fauces, the parts may appear somewhat swollen, and of a dark colour; and should there be any ulceration, it will perhaps be ash-coloured, and look indolent. It may be stated, and with some plausibility, by that class of practitioners who are led only by symptoms, that those just described do not denote the existence of scarlatina; to which it may be replied, that one individual of a family will display such symp- toms, while others are labouring under the disease in the ordinary form. Similar appearances have also come on in the coursejof scarlatina, upon the sudden disappearance of the rash; and further, the cessation of the congestive symptoms has been witnessed upon the re-produc- tion of the rash; which phenomena have occurred so often, that 1 am compelled to receive them as part of the medical evidence. I have had one opportunity only of examining the body after death, in a subject who fell a victim to this form of the complaint. The throat was found to be very slightly ulcerated. There was considerable distension of the veins in the abdomen, the lungs were much con- gested, and the vessels of the head were remarkably full of dark- coloured blood. The pure congestive disease is rare, but it is very common to see the mixed disease, that is, a combination of the inflammatory with the congestive symptoms. The inflammatory form of scarlet fever generally makes its attack in the following manner:—rigors, or only slight chilliness, followed by more or less pyrexia, restlessness, want of appetite, thirst, want of sleep, headache, some degree of nausea, oppression in the praecordia; SCARLET FEVER. 191 tongue at first slightly loaded, red, with raised papillae; or it may be much loaded with a yellow fur, and intensely red at the tip and round the edges. Soreness of the throat is complained of, which is some- times the first cognizable symptom; it is either slightly swollen and much inflamed, or of a dusky hue, without'much swelling; ash-coloured ulcerations may often be discovered, but we must be upon our guard not to mistake exudations of coagulable lymph for ulcerations. In the generality of cases, there are evidences of sub-acute inflammation in the larynx and bronchi, which is announced by difficulty of breath- ing, cough, and hoarseness, and more particularly by auscultation; but the inflammation in the bronchial tubes is not so decidedly marked in all cases of scarlatina, as in measles and small-pox. Sometimes there is delirium, but perhaps during the course of the night only, and sometimes some degree of coma. These symptoms may continue for 2, 3, 4, 5, or 6 days, before the rash makes its appearance. Some- times, indeed, the eruption is the first symptom which announces the complaint, but this happens in the mildest cases only. In general the eruption appears on the 4th or 5th day. The eruption is of a scarlet colour, first to be observed on the face and neck, and in the course of twenty-four hours it becomes pretty generally diffused, patches appearing here and there more intensely red than the surrounding parts; on pressing with the finger a white mark is left, but the redness returns in a moment afterwards. After the eruption has existed from 3 to 5 days, it begins to decline, the cuticle* subsequently separates and peels off. This is a very dangerous stage of the disease, and would be still more so, were it not that the eruption declines gradually, and that the circulation on the surface is still actively employed in the formation of new cuticle for the whole surface. Dr. Gregory, in his lectures, used to state, that " a copious efflores- cence is a favourable symptom; when it is deficient the symptoms are more severe, and when it is repelled, it never fails to aggravate both the general fever, and the topical affection of the throat." -It is not an easy matter," continued he, "to explain the connexion which sub- sists between the efflorescence and the other symptoms; it is not critical, but all the symptoms are much relieved by its coming out copiously." Occasionally anasarca, and more rarely ascites, follow in the first or second week, and are attended with constipation, scanty urine, languor, nausea, general uneasiness, and other symptoms which have been de- nominated secondary fever. 192 SCARLET FEVER. [It is also not unusual to see inflammation and suppuration of the glands of the neck, sometimes extending to both sides, and causing great destruction of the parts involved. Whenever this tendency is observed, it should be combated by the immediate application of leeches, followed by emolient poultices and gently stimulating lini- ments. 1 have in this way sometimes succeeded in arresting the pro- gress of inflammation; but it will often goon to suppuration, and form large abcesses. When there is nohemorrhagic tendency, these may be opened with a lancet to prevent a scar, and circumscribe their ravages. There is another appearance not so often met with, but much more to be dreaded—the hemorrhagic form of scarlet fever. It usually commences by small purple spots under the cuticle of the chest and ex- tremities. Some oozing of blood next follows from the mucous mem- brane of the mouth and nose, which sooner or later becomes profuse, and the patient eventually bleeds to death. If a vein has been opened in the arm, or an abscess .lanced in the neck, the incisions become a source of hemhorrhage: and in a case that occured in my practice in the winter of 1S34-5, and which was seen by Drs. J. Rhea Barton and Wood, abscess in the neck suddenly filled with blood, and the latter making its way through a leech bite, flowed out as if from a divided artery, and destroyed the patient in a few hours.] Appearances on Dissection.—In the dissections which have fallen within my observation, the inflammation and ulceration in the throat have not appeared so extensive and important as had been imagined before death. The most constant diseased appearances have existed in the air passages, presenting inflammation in its different stages; viz. vas- cularity of the mucous membrane thickening, and occasionally ulcera- tion; in two cases I have seen the epiglottis nearly destroyed by ulceration; and also effusion of thick, tenacious matter, filling up the air passages to the bifurcation, and often lining the trachea. Some- times the substance of the lungs is seen inflamed, and occasionally the pleura, but traces of inflammation in these two tissues are not so frequently met with, and are to be regarded more as examples of acute action, extending from one tissue to another by contiguity, than as forming essential parts of the disease. The lungs are sometimes so much gorged with blood, as to have lost in a great degree their natural appearance and buoyancy. In the brain there is somtimes arborescent vascularity, with turbid effusion between the arachnoid and pia mater, and the ventricles are occasionally filled with serosity. On opening the abdomen, the peritoneal coat of the stomach and bowels generally looks healthy, except in the congestive cases, when the minutest SCARLET FEVER, 193 blood-vessels will be seen distended with dark-coloured blood. In different parts of the mucous membrane, we frequently see consider- able vascularity, sometimes ulceration. The liver is often gorged, or soft in texture. "From a cautious survey of the symptoms during life," says Dr. Armstrong in his work of Scarlatina, &c. page 16, "and from the ex- amination of several bodies after death, I am warranted in affirming, that the brain, the liver, the stomach, the intestines, and the lungs, are the parts most often inflamed, and that the inflammation in these parts is generally the cause of death, together with the affection of the throat." Treatment.—In scarlatina, as in other diseases, differences in patho- logical opinions have of course given rise to dissimilar methods of treatment. Some, considering it a disease of debility, recommend bark, and wine, or brandy, with nourishment, and condemn antiphlo- gistic means as highly dangerous; in this class of symptomatical writers stand Underwood and Dr. .tomes Hamilton, Jun. It will not surprise my readers, that the first named individual, who did not live long enough to profit by modern pathology, should have taught the doc- trines that prevailed in his own time; but considering the account which every author gives of the symptoms and'course of this disease, and the appearances on dissection, it is lamentable to reflect that there is one author of the present day, who speaks doubtfully even of local bleeding pi scarlatina, and who recommends cordials and nourishment, and even wine itself, in large quantity. But all this does Dr. James Hamilton, Jun.* He goes even the length of quoting a great medical authority, the head master of a boy's school in Yorkshire, in whose practice among the said boys, " it was found that children under 15 years of age, affected wijh this disease, required within the twenty- four hours, sometimes not only a bottle of port wine, and another of raisin^ but also a proportion of brandy."t Poor boys! Underwood, in describing the treatment necessary in this disease, makes the following extraordinary statement: " Should the affection of the throat, therefore, be evidently inflammatory, or should a case occur where the fever may seem to be of that kind (which may be better ascertained by the hardness of the pulse than any other symptom) it will very rarely bear bleeding, even in the beginning of the disease; as symptoms of debility generally attend in some period of the scarlet * Vide his work on the Dim ,ises of Children, p. 380. t Management of Children, p. bsl, Ed. lb'24. Vol. I.—25 194 SCARLET FEVER. fever, and will allow only of that middle course of treatment hinted at above. In a general way, a cordial plan is required throughout the disease."* And yet, on turning the next page, it will be found he recommends bleeding in the secondary fever; and he also tells us, that a critical bleeding from the nose has saved life, when the patient's state " has appeared very hazardous, and the prostration of strength been considerable." In the slighter forms of scarlatina, very little treatment is necessary, further than confinement, attention to the bowels to keep them free, and the antiphlogistic regimen. In such cases, however, the medical attendant should be careful to watch diseased action, at the period when the eruption naturally declines, for reasons already mentioned. I used formerly to see fatal cases of scarlatina, when I practised accord- ing to the opinion of the schools, carefully abstaining from blood-let- ting, and using all the means recommended to support the strength; but it occasionally occurred to me to see patients snatched from the grave by considerable bleedings from the nose, and at times when it was thought the loss of an ounce of blood would prove destructive. These circumstances,together with the appearances found on dissection, led me to bleed in many subsequent cases, and I have never had occa- sion to regret it. Blood has been drawn at all periods of the disease, in cases where the state of the lungs and brain required it; and should the operation be performed during the period of the eruption, it will disappear, if a sufficient quantity of blood be taken. Wh,en the in- flammation of the throat runs very high, 1 know no remedy produc- tive of such certain and immediate good effects as general bleeding; but should the patient's strength be already reduced, leeches are to be preferred. Dr. T. P. Lucas of the Royal Artillery, and Dr. Wilson, cannot have forgotten the case of Ann M'Farlane, aged IS, which they treat- ed, when they were my pupils in the year 18-24; from whom they took above §xx of blood, with instant good effect, on the fourth day of the disease, when she had a large sloughing ulcer occupying- the whole of the right tonsil. She afterwards required no other remedies but laxatives, and in a fortnight returned to her usual occupation. A great many other gentlemen, who have been pupils at my dis- pensary, can be appealed to, and I may refer in an especial manner to the testimony of my talented colleague, Dr. Robertson, who was op- posed to the practice of general bleeding in scarlatina, till he saw the * A Treatise on the Diseases of Children, p. 289. SCARLET FEVER. 19.") success of it. [The medical profession in the United States is divided in opinion as to the use of venesection. In my own practice 1 have resorted to it in every severe case, and with the most gratifying; results. It is almost in vain to treat the congestive form in any other way; and in the violently inflammatory disease there is no substitute for the lancet.] When general bleeding is either inadmissible, or not thought necessary, or when the child is under two or three years of age, local bleeding by leeches will be found highly serviceable. When the throat is extensively inflamed, although the accompanying symptoms may be mild, I always think it right to reduce the inflammation by the application of leeches, followed or not by a blister, according to circumstances. Laxative medicines, frequently repeated, are very necessary. Spunging the body either with tepid or cold water, pro- duces good effects, by allaying restlessness. Cold affusion may do no harm in the slighter forms of scarlet fever, but in the severe cases which invariably display marks of internal disease, and in which con- gestion has taken place, its use cannot be defended. The tartrate of antimony has been long employed in this country in the treatment of fevers and inflammations, and it has been found very serviceable in this disease, by controlling the action of the heart, and relieving uneasiness. It may be used in the diseases of children, by dissolving one or two grains in two ounces of water, a tea spoonful for a dose as often as may be thought necessary. GSrgles may certainly be employed, and those of a stimulating na- ture are much lauded; but it appears to me that the best gargle is a little warm water; and I particularly caution young practitioners against attempting to syringe the throat of a young child. Inhalation of the vapour of warm water will be found to ease the throat more than any gargle. [But after ulceration or sloughing have commenced, stimulating gargles contribute greatly to- convalescence. Nothing has been found more efficacious in the United States than Cayenne pepper, either infused in water, or mixed with vinegar, and frequently used. Diluted port-wine, the black-oak bark, and common green-tea may also be used with salutary effect* The too early use of such applica- tions, however, is hurtful for obvious reasons.] Opiates are often ser- viceable in the last stage, and during convalescence, to allay irritabili- ty, and procure sleep. Since the alteration which I have adopted in practice, I rarely see secondary fever or dropsy; but too great care cannot be taken during recovery, and the patient should be cautioned against the risk that he will run from exposure, errors of diet, and neglecting the state of the 196 MEASLES. bowels. Should dropsy take place, it will in general be found to be of the acute kind, and will sometimes require the lancet, although brisk purgatives, with diuretics, will in general suffice. In conclusion, it may be mentioned, that various affections occa- sionally follow scarlatina, as inflammation, and swelling of the glands, and perhaps more particularly of the parotid, which must be treated upon ordinary principles. Inflammation often attacks the internal ear, leaving a fetid discharge, followed on some occasions by incurable deafness, which must also be treated by appropriate means. These and other appearances following scarlatina, are commonly known by the term " dregs" of the disease. MEASLES. Measles may also be defined to be a disease attended by fever and an eruption, which appears at various periods, but generally at the termination of the fourth, or beginning of the fifth day, and continues for three, four, or five days; after which, some discolouration is left on the surface of the body, and occasionally the cuticle separates, but not so invariably as in scarlatina. Measles has been divided into four varieties: 1*/, rubeola vulgaris. 2d, -------sine catarrho. « 3d, -------nigra. 4th, -------putrida. Pursuing the same pathological plan which has been adopted when treating of scarlatina, I shall also mention two great varieties of mea- sles, the congestive and the inflammatory. In the first species, which has been so well illustrated by Dr. Arm- strong, re-action does not take place; or if it do, it is slight; the erup- tion is trivial; the pulse is feeble and oppressed, perhaps quick; ajid the surface is free from that redness and heat which give such a striking external character to the pure inflammatory disease. This is, no doubt, one form of the complaint called "putrid," and which has been de- scribed by Morton, Huxham, and Watson. The same pathology that was maintained in scarlatina, and also in the general statement concern- ing eruptive fevers, equally applies in this case; and renders it unne- cessary to repeat the observations. Capuron, in his treatise on the diseases of children, at page 293, makes the following statement:—"One of the most dreadful compli- MEASLES. 197 cations of measles, is that with an ataxic or malignant fever. Indi- viduals naturally lively and delicate, as those in infancy, are more subjert to it. It is one of those unlooked for anomalies in the vital properties. The functions of the brain are disturbed; respiration is deranged, and becomes extremely constrained; in a word, the patient is quickly reduced to the last extremity, if something be not done for his relief. The most active treatment is here indispensably necessary to sustain life, which is shaken to its very foundation." Subsequently he states, that " infants naturally weak, or who live under the influ- ence of debilitating causes, are exposed to an adynamic or putrid fever during the course of the measles. One detects this dangerous com- plication by the change in the form and colour of the spots;—from being at first prominent, and of a lively red, they become more de- pressed, pale, and livid; in which case, we must prevent the prostra- tion of strength in good time, and direct the eruption back again towards the surface of the body by the use of tonics, such as wine, bark, and camphor; the greatest advantage may be also obtained by epispastics, and above all, by blisters." At page 291, he again ob- serves, " there are infants in whom the progress of the eruption is arrested, the spots disappear, and pains in the chest, more or less severe, manifest themselves; respiration is oppressed; pcripneumony declares itself; suffocation is threatened." Mr. Burns of Glasgow, in detailing the symptoms of measles, states, that "sometimes the eruption suddenly and prematurely recedes, or never comes fully out. Both of these cases are unfavourable, the fever is high, and the oppression great." It will be seen, by consulting the report of diseases treated at the New Town Dispensary of Edinburgh, during the last six months of the year 1S1G, published in the 13th vol. of the Edinburgh Medical and Surgical Journal, that this form of the disease was very prevalent, and that few children recovered; most of those attacked were of feeble habit, or weakened by previous ill- ness, " but others appeared to have been quite healthy when exposed to the contagion." " Those affected in this way were chiefly infants, but a few were children from four to seven years of age. They were ill longer than usual, generally five or six days, before any eruption appeared, having the usual catarrhal symptoms, with much debility and drowsiness; frequent vomiting; generally frequent, and some- times bloody stools; quick pulse, and white tongue, without much heat of skin. When the rash appeared, it was at first less distinctly circumscribed, and afterwards less elevated than usual, of a darker colour, and attended with less heat of skin. After its recession, the 198 MEASLF.P. patients were more or less distressed with cough and dyspnoea, ge- nerally with diarrhoea, and almost always with a frequent ineffectual attempt to vomit. The pulse and breathing became very quictc? tne tongue, after losing the white crust which had covered it at the begin- ning of the disease, became dry and hard; the posture indicated much debility; the countenance had the languid, vacant expression of typhus: and a dark-coloured fur usually gathered on the lips and teeth. In all these cases, there was a degree of drowsiness approaching to coma; and in a few, this state appeared to be blended with delirium. "In two or three instances, infants exposed to the contagion of measles, became affected with catarrhal symptoms, fever, drowsiness, quick and oppressed breathing, and died, without any eruption being observed. " In the cases of speedy recession of the rash, if the cough and dyspnoea were urgent after its disappearance, death almost univers- ally ensued, from the first to the fourteenth day after that change. But those in whom the pectoral symptoms were less distressing, re- covered from the state above described, under the use of wine and cordials, which, as far as we could judge, were as decidedly beneficial in these as in any other cases in which we have seen them used. It should be mentioned, however, that one or two, who could not be prevailed on to take either food or medicines, gradually mended without any crisis being observed. " On opening the bodies of those who had died of this form of measles, a considerable accumulation of mucus in the bronchia was always found. In two infants, under a twelvemonth, there were marks of inflammation of the lungs, (which in one of these had pro- ceeded to ulceration,) and a good deal of water was found in the peri- cardium. In one child, four years of age, there was such a conges- tion of blood in the lungs, that a large portion of them sunk in water. In several cases, in which the eruption had almost or entirely dis- appeared on the second day, it re-appeared that night, after the use of the warm bath, and an opiate, and continued nearly the usual time. An amphthous state of the mouth and tongue occurred pretty fre- quently, but was not confined to the unfavourable cases. The circumstances of the livid colour, and rapid recession of the eruption, of the succeeding ty phoid state, and the irritability of stomach • attending that state, seem to point out a resemblance between the cases of measles now described, and the worst cases of scarlatina. I scarcely think that such appearances support the wine and cordial treatment, which, we are told, was had recourse to in these cases. It MEASLES. 199 has fallen to my lot to treat a considerable number of cases of this kind; and the plar> which experience has led me to adopt, is, first to try the warm bath with stimulating frictions; but if the symptoms be very threatening, such as coma, convulsions, or asphyxia, or an approach to these states, the best practice, if the patient be an adult, or even a child, if a vein can be found, is to bleed at once. Several interesting cases might be detailed, showing the advantage of this plan; I shall now merely give a short sketch of one. A few years ago, I was called suddenly to see a child in measles on the first day of the eruption; every appearance had been so favourable up to the moment of the sudden recession of the rash, that the family had not applied for medical advice. On my arrival, the eruption, which had been extensive, and of the usual colour, was not to be seen, although it still was to be felt. The child was under three years of age, and of good constitution; it had had thrpe or four strong convulsions in the course of rather less than an hour, and was now comatose; one pupil dilated, while the other was of the natural size; the hands were clenched. A good sized vein being found in the arm, was instantly opened, and from eight to ten ounces of blood abstracted, when the breathing, and every other appearance, became more favourable; the pulse, which was under sixty, rose gradually as the bleeding went on, and the child soon became quite sensible. So far from debility follow- ing, it was necessary to apply leeches next day to the head; the child made a rapid recovery, and was running about in the course of a week. In every respect, the treatment must be conducted in the manner detailed in congestive fever, as well as in the congestive form of scarlatina. The inflammatory disease is the form most generally met with; we have the usual eruptive fever, preceded by rigors, depression, and debility: along with the fever, the patient has a dry cough, with hoarseness; frequent fits of sneezing and coryza.* He also complains of giddiness and pain in his forehead, as well as in the back; his pulse is various, sometimes frequent and small, or frequent and strong, often it is irregular and oppressed; the bowels are generally confined, and the evacuations fetid. In the course of the second, third or fourth day of the fever, the symptoms run higher; the eyes are ten- der, red, watery, and inflamed; the dyspnoea, which was slight at first, is now more severe; the patient complains of tightness of the chest, pain, and oppression at the praecordia. The eruption appears first on the face and neck, in twenty-four hours it is found on the breast, and afterwards gradually spreads over the rest of the body; it consists of 200 MEASLES, small red papulae, slightly elevated, resembling recent flea-bites; these soon form themselves into extensive patches, irregular in shape, their margins having somewhat of a crescentic appearance. The eruption is sometimes very extensive, at others slight. The throat, when ex- amined, will be observed to be covered with small red patches, occa- sioning difficult deglutition. Sometimes immediately before the eruption comes out, the patient is seized with violent sickness and vomiting; sometimes with convul- sions; but if the eruption subsequently comes out freely, these symp- toms abate. In a great majority of cases, the disease is rather slight, and the in- ternal disturbance, which is discovered by the symptoms already de- scribed, is generally very much appeased soon after the appearance of the eruption, particularly if it come out freely and plentifully. Occa- sionally, however, the symptoms are very severe from the beginning; the cough is frequent and harsh; there is considerable dyspnoea with hot skin, thirst, and a quick pulse; and the child is occasionally so comatose, that this symptom early attracts our attention. As the embarrassment of the lungs increases, which may happen in any stage, the face becomes discoloured, and sometimes presents a purple appearance, and occasionally the eruption over the whole body assumes a dark colour; this'is the state which is called 'rubeola nigra, and is probably that form of the complaint described by Dr. Watson and others, under the term Putrid Measles. After the natural disappearance of the eruption, the fever, dyspnoea, and cough, in some cases increase, attended or not with considerable gastro-intestinal irritation and diarrhoea; occasionally inflammation of the eyes, enlargement of the glands of the neck, succeed. Blistered surfaces frequently slough; and it has been remarked by Dr. Watson, Dr. Ferriar, of Manchester, and others, that an ulceration of a particu- lar character attacks the pudendum of girls, from wMch few recover; three cases have fallen within my observation, two of which proved fatal; and it is my opinion that death is not owing to this ulceration, but to internal disease. Dissection, in two of these cases, displayed extensive disease of the lungs, but more particularly ulceration of the mucous membrane of the intestines, of which the preparations and drawings are in my museum. '* * This is the disease which has been described in the 7th vol. of the .Med. Chir. Trans, of London, by Dr. Kinder \\ ood, who saw twelve cases, of which only two recovered. The case of recovery which I have noticed, was under the • MEASLES. 201 Appearances on Dissection.—Morgagni notices the following case, which he says has been transferred from Ballonius into the Se- pulchretum: " On examining the body of a person to whom it was suspected that poison had been given, the stomach was found beset with exanthemata, and the physicians were upon the point of assert- ing that the appearance was owing to poison, when they were in- formed that the person died of measles, which began to appear on the skin, and suddenly vanished." In the examinations at which I have been present, effusions and other marks of inflammatory action have been found in the brain, and sometimes ulceration in the mucous membrane of the bowels: but I have seen no dissection in which the pulmonary system escaped. The lining membrane of the bronchia, trachea, and larynx, has not only been found in a highly vascular state, but it has been thickened, softened, and occasionally ulcerated; the ulcers are small, and gene- rally situated near the bifurcation; the bronchial tubes are more or less filled with a matter like pus or thick mucus, as in bronchitis; the colour of this secretion varies; and it is sometimes tenacious, at others not so. This condition of the air passages has always existed on both sides of the chest. In many cases, the lungs are found emphy- sematous, in others, inflamed in different degrees; the inflammation rarely affecting both lungs, and it is frequently confined to one lobe. Occasionally there are extensive inflammations of the pleura, indi- cated by effusion of serum and exudation of coagulating lymph, be- sides thickening of the pleura and recent adhesions; and in cases of longer standing, tubercular formations are observed in different de- grees of advancement; sometimes even excavations of the lungs. It ought to be noticed, that the inflammatory appearances in the brain and bowels, together with the disease of the substance of the lungs, and the pleuritic effusion, are to be regarded as accidental cir- cumstances; whereas the inflammation of the bronchial membrane is * an essential part of the disease, and may be traced from the begin- ning of the complaint. Treatment.—In the slighter forms of this disease, as in scarlatina, very little treatment is necessary, further than confinement to one room, the free exhibition of gentle laxatives, and low diet. The medi- cal attendant should be still more watchful in this disease than in care of Dr. Moffit of the 7th Hussars; the patient was a soldier's child. The disease followed a very slight attack of measles. For an account of this singu- i lar disease, vide Vol. ii. p. 303. Vol. I.— 2« 202 MEASLES. scarlet fever, at the period when the eruption naturally recedes, for reasons already mentioned. In the severer forms of measles, bleeding is often necessary during the eruptive fever, when the pectoral symp- toms run high, and appear threatening; and also when coma and con- vulsions take place, both of which are more likely to happen, but par- ticularly the latter, if the child be suffering from difficult dentition. I was called once to see a fine boy of two years of age, who, during the eruptive fever, was seized with convulsions in the night, at the period when the eruption ought to have made its appearance, and from whom nine ounces of blood were taken. Next day he had nine or ten leeches applied to his head: the symptoms were afterwards ex- ceedingly slight, and he made a rapid recovery. He bore the bleed- ing without any tendency to syncope, while his brother, a boy of twelve years old labouring also under the same disease, and who re- quired blood-letting for pectoral symptoms, fainted upon the loss of two ounces. When bleeding is necessary, it ought to be performed in the man- ner already described when treating of inflammatory fever; a sufficient quantity should be taken as early as possible in the disease, and the operation ought to be repeated at short intervals; but when the bron- chitic symptoms have been allowed to go on neglected till the air pas- sages are gorged with mucus, bleeding is a very questionable remedy, and no doubt often does irreparable mischief, for reasons which will be fully noticed when treating of bronchitis. Leeches are to be em- ployed as directed in scarlatina, and also blisters.* Antimony is also highly serviceable; and opiates in the last stage, when there is rest- lessness and irritability, if the air passages are not filled with mucus. The warm bath affords much comfort to the patient in all the exan- themata, every night, or every other night, after the eruption has de- clined, and when the cuticle is exfoliating. During recovery, great attention should be paid to the diet, clothing, and state of the bowels, so as to avoid the disagreeable circumstances which so often follow the exanthemata, viz., the formation of tubercles in the lungs; inflam- mation and ulceration of the mucous membrane of the bowels, pro- ducing the disease which is called tabes mesenterica, and also glandu- lar affections of the neck, inflammation of the eyes, and chronic erup- tions of the skin. * When a blister is applied to a child, uuder any circumstances, the part should be carefully examined daily by the medical attendant, but more particularly in the eruptive fevers. SMALL-FOX. 203 This is a very different line of treatment from that which is still recommended by Dr. James Hamilton, jun., and which is founded upon the most curious notion that can well be conceived, viz., that the bad symptoms in measles are not occasioned by inflammation, but by " torpor of the lymphatics." But as this statement may not be credited, Dr. James Hamilton, jun. shall be allowed to speak for him- self. At page 377 of the work already quoted, last edition, the fol- lowing passage will be found: " As the debility which always attends and follows measles is the most prominent feature in the progress of the disease, it is not easy to understand the reasons why practitioners have been led to overlook so obvious a circumstance. The objections to wine and nourishing diet, which it is so often necessary to combat, probably arise from the supposition, that the frequency of the pulse and cough are the effects of inflammation, when in fact they are oc- casioned by the torpor of the lymphatics!!!" SMALL-POX. This disease commences with rigors, followed by febrile symptoms, which continue from forty-eight to sixty hours, and even longer, be- fore the eruption appears; and it is no uncommon thing for children to be seized with convulsions during this period. The attack is fre- quently very sudden; vomiting generally occurs; there is pain in the head and back; and the patient complains very much of oppression at the praecordia, and a pungent pain in the pit of the stomach, much in- creased on pressure; there are also decided marks of general disease of the mucous membranes, and more particularly that of the bronchi, announced by dyspnoea, cough, and wheezing. Physicians have divided this disease into two kinds, from the form which the eruption assumes. When the pustules do not run into each other, the disease is termed distinct; when they are very numerous, and run into each other, it is termed confluent; all the symptoms be- ing more severe, and attended with more danger than in the former. The eruption first appears on the face, in the form of small red pa- pulae. About the third day, a vesicular appearance is observed on the top of each spot, which is soon depressed in the centre, and is found to contain a transparent fluid, with an inflamed circular margin. About the sixth day the eruption loses the depression in the centre, and in- stead of serum, will now be found filled with a puriform matter. When the pustules are numerous, the parts swell much, and the neigh- 204 SMALL-POX. bouring skin is of a red colour, from the extension of the inflammation. About the seventh day, some of the pustules on the face burst, and upon the eighth or ninth they begin to dry and scab over the rest of the body. The swelling which affects the face, hands, and feet more severely than other parts of the body, gradually declines; the skin remains of a dark brown colour after the scabs fall off, and it is many weeks before the surface recovers its natural appearance. This is the course which the distinct small-pox generally runs, and when treated properly it is rarely fatal, every thing depending upon the state of the lungs and brain. In the confluent small-pox, all the precursory symptoms are more severe; the eruptive fever runs higher; the pain in the epigastrium and dyspnoea are more complained of; convulsions and delirium also more frequently take place; and the patient runs more risk of secon- dary fever, and danger from extensive inflammation, ulceration and sloughing of the skin. In both varieties, but particularly in the confluent, copious salivation sometimes takes place, and soreness of the throat is a marked symp- tom; upon examining the mouth and fauces, vesicles or pustules may be observed as far down the pharynx as the eye can reach. I have seen the same appearance on the mucous membrane of the rectum, in a case of small-pox in which there was prolapsus ani; and in the year 1823, a great number of my pupils had an opportunity of seeing a similar case. I am not aware whether this appearance in the fauces and rectum follows an increase and decline simultaneously with the eruption on the skin. In some severe cases, petechiae are seen, when the eruption has begun to declinej bloody vomiting and diarrhoea with tenesmus, take place; and the dyspnoea frequently increases as the dis- ease advances. The inflammation in the skin is frequently so deep and severe, that the death of a portion takes place, perhaps of the cellular substance, as in carbuncle; and this is one cause of what are called pock-marks. In small-pox, as well as in other acute diseases, there is a congestive form, in which the system is unable to raise sufficient re-action: there is consequently more oppression; the surface is pale; the eruption flat, and never matures properly; the dyspnoea is very considerable; and I verily believe this is the form which is called the most malignant. In severe cases death takes place before the eighth day; but, gene- rally speaking, the fatal event happens sometime between the tenth and seventeenth days. The proportion of deaths is said by Dr. G. Gregory, who must be a very good authority upon this subject, to be SMALL-POX. 205 about one in every six persons who receive the small-pox in the natu- ral way. But during the prevalence of an epidemic, the mortality is sometimes one half. Indeed, it appears that during a severe epidemic at Ceylon in 1819, the number of native inhabitants taken into the hospital at Kandy, amounted to 931; of these 525 died. Since the publication of the first edition of this work, I had occasion to attend 50 cases of small-pox, all of which were distinctly traced to the im- prudence of a woman who exposed her unvaccinated child to the contagion, when visiting a sick friend. Of these 50 patients, 35 had gone through the process of vaccination; 15 had never been vaccina- ted, (they were infants under one year of age.) All the protected cases recovered. Of the 15 unprotected cases, 10 died. Three only of these had the disease slightly. Of the five children who survived the attack, one did not recover perfectly, and died of chronic bronchitis some months afterwards. Appearances on dissection—Head.—I have seen marks of inflam- mation of the membranes, evinced by a considerable arborescent vas- cularity on the surface of the brain, the vessels of the pia mater being greatly loaded with blood, together with effusion under the arachnoid, and into the ventricles. But it becomes me to speak with diffidence with respect to this part of the subject. Dr. George Gregory says, at page 105, that he has " never been able to trace any morbid appear- ance in the head," which is rather at variance with the results of my limited experience, and with a statement which he subsequently makes at page 108. In directing the mode of treatment, he says, " It is to be remembered also, that in small-pox, fully as much as in any other form of fever, there is a tendency to congestions and inflammations in the head and thorax." " A patient," (says Batting, p. 76,) " during the cure of a very extensive fracture of the skull, was seized with small-pox, &c. &c. It was curious to observe in this patient, the ap- pearance of variolous pustules upon the granulations of the dura mater." Although I have been prevented, by the impatience of surviving friends, from opening the head as often as I could have wished, yet many opportunities have been afforded me of examining the contents of the thorax and abdomen. 1 have seen pustules in the pharynx, la- rynx, trachea, and oesophagus, in those who died on or before the twelfth or thirteenth day, on some occasions closing up the larynx. The mucous membrane of the bronchi very vascular, and the air tubes completely gorged with matter, most frequently of a reddish colour; but in no instance have I been able to discover a pustular appearance 206 PMALL-POX. below the bifurcation. The substance of the lungs congested with blood, and in the first and second stages of inflammation; and in one instance there was pleuritic effusion. On examining the body of a deformed girl, who died under an attack of confluent small-pox, the peritoneum and pleura were studded over with small circular spots, which looked like a faded eruption; but perhaps they might have been produced in the manner which we sometimes see in cases of purpura. I have observed nothing in the stomach to account for the severe burn- ing pain complained of in the epigastric region; the mucous membrane has certainly shown vascularity, and has been covered with a viscid exudation, the follicles being much increased in size, which appearance often extends throughout the whole intestinal tube; and in three or four instances I have seen ulcers having a pustular appearance, with a depression in the centre, in the jejunum, ileum, and also in the large intestines, of which the preparations and drawings are in my museum; and some of them were surrounded by an inflammatory areola. Treatment.—Small-pox under every form is a serious disease; for however mild it may appear in its attack, its consequences are always to be dreaded. The confluent, however, is a very dangerous disease; and we are to be guided in the treatment by observing the state of the brain, and the organs contained within the thorax, as well as the con- dition of the surface of the body. It was formerly the custom to keep the patients very hot, and to employ stimulants; and the consequence was, that the mortality was immense; but for many years past, patients have been kept cool, and the antiphlo- gistic regimen recommended, but I fear, too little practised, from the dread of putridity. Bleeding has been often employed, and strongly recommended, in this disease, particularly during the eruptive fever; but it has as often been condemned, because it destroyed that strength which, it is alleged, is so much required in the latter stages of the dis- ease. But the same language is used in the purest inflammatory fevers. In all the successful cases of confluent small-pox, occurring in adults, which 1 have treated, except one, amounting in all to about eighteen, bleeding was employed, and largely employed, in the eruptive fever, to moderate what was thought to be local inflammation, without sus- pecting that they were cases of small-pox; several of the sufferers were my pupils, who had had themselves bled before I was called in. In a number of instances blood has been drawn even after the appearance of eruption, and with decided benefit; but upon the whole, 1 am then disposed to trust more to leeches for relieving local inflammations. The state of the throat and air passages requires daily and minute ex- MODIFIED SMALL-POX. 207 amination; and after the eruption comes out, the application of leeches to the neck, and also to the chest, is often necessary to reduce inflam- mation. Bleeding before the appearance of the eruption may be ex- pected to moderate that symptom, which is of the greatest consequence, as many die from the severity and extent of the external inflammation. The appearance of petechiae does not prevent me from ordering the application of leeches, in cases which require this practice. With re- spect to other points of treatment, they are similar to those which have been recommended in scarlatina, measles, and other febrile diseases. I may be allowed, however, on this occasion, to insist on the pro- priety of trusting to nature a little more than is generally done, when the patient begins to convalesce, avoiding attempts to hurry it on, and restore the strength, which, in a great proportion of cases, is the cause of secondary fever. A number of disagreeable circumstances often take place as sequels of small-pox, and the most painful one is the for- mation of boils on various parts of the body, and sometimes even car- buncles, of which there are successive crops tormenting the patient for weeks. Glandular affections also frequently follow, as well as oph- thalmia tarsi and ophthalmia purulenta. 1 can state from experience, that it is a good plan to open the pustules on the face early, in order to prevent marks. MODIFIED SMALL-POX. [ Varioloid.] There are several circumstances which are said, in medical language, to modify this horrible disease. The mysterious power of vaccination in preventing small-pox is now admitted; experience, however, has taught us, that this antidote does not always succeed; but the generality of cases of small-pox which follow vaccination are very mild. Indi- viduals are sometimes attacked also a second time with small-pox, and in my comparatively limited experience, I have known upwards of twelve well authenticated instances. The first attack is generally supposed to modify the second, and to render it milder; but it is curi- ous, that all my cases of secondary small-pox, with the exception of two, were remarkably severe; whereas I have never seen a severe case of small-pox after vaccination. Previously to the great discovery of Dr. Jenner, respecting the power of vaccination in preventing small-pox, the disease was mo- 208 [COW-POX.---VACCINATION.] dified, and rendered less severe and fatal, by inoculation. This prac- tice had been long followed in the East, and was introduced into this country from Turkey, by Lady Mary Montague. An interesting question arises, to determine why the inoculated small-pox should be so much milder than the natural? This is, perhaps, easily answered. A proper season of the year is chosen for the operation; the patient undergoes a certain preparation, and his bowels are particularly attended to. In the modified disease, the stages are all shorter, and the eruptive fever is slighter; the convalescence is less tedious, and the sequelae are not so troublesome. This disease must be treated according to the general principles hitherto laid down. [Cow Pox.*— Vaccination.] [We owe the discovery of vaccination to Dr. Jenner. He observed that those persons who milked cows affected with the disease called Cow-pox, were exempt from the small-pox—whence he inferred that an equal immunity might be derived from the artificial insertion of the virus of the former eruption. Experiments proved the truth of this inference, and vaccination is now justly regarded as one of the greatest benefactions that medical science has bestowed upon the human race. Vaccine matter is perhaps most certainly efficacious when taken before the tenth day of the eruption; but experience has amply proved, that a mature scab is capable of retaining all its virtues for many weeks after its separation from the arm.t Whether we use the fluid matter from the pustule, or the dried crust, the best mode of inserting it is on the point of a lancet, about the middle of the arm, care being taken to make five or six oblique punc- tures into the cutis vera, without drawing blood. These punctures should be confined to a very small area, say about two lines in diame- ter. If the dried scab is used, it must be rubbed to a thin paste with water, and after its insertion the spot should be allowed to dry with- out interruption. With these simple precautions vaccination is per- formed with almost uniform success, and with the following appear- ances:— [* This disease is not noticed in the original work.]—Ed. [f If enclosed in wax it will retain its virtues for a much longer period.]—Ed. [vaccination.] 209 No obvious change is observed until the third day after the inser- tion, when a minute inflamed spot is seen. As the inflammation pro- ceeds, a small, circular, flattened and slightly elevated tumor is formed. About Jlhe sixth day the pustule begins to assume the vesicular charac- ter, thesecretionof matter taking placein the centre,and increasinguntil the tenth day, when the perfect vesicle is produced having the follow- ing characters:—It is circular or oval, with a distinct, smooth,- turgid margin, and a depression in the centre:—the contained matter being of a uniform pearl colour. After the eighth day the vesicle is surrounded by a bright-red areola, varying in diameter from less than an inch to two inches, and accom- panied by a radiated tumefaction and hardness of the subjacent parts. On or before the twelfth day, the areola begins to decline, at which time the vesicle becomes discoloured, and of a greater firmness, and in a few days more is converted into a scab of a dark mahogany colour, which becomes blackish as it dries, but retains its smooth surface. This scab separates about the fourteenth day, leaving a cicatrix which is circular and slightlj' depressed, and presents a number of minute pits or depressions. The constitutional symptoms are usually so slightas to require little or no attention:—they consist in a slight fever about the eighth day, with some tumefaction of the axilla, which pass off with the local affection. These are the appearances, and the order in which they occur, in unequivocal vaccination. Slight abberrations may occur without lessen- ing confidence in the result; but there are some other deceptive appearances against which it is necessary to provide. These, which have been called spurious vaccination, are enumerated by Dr. Willan as follows:—merely premising that it is not unusual to see a common conical pustule, having no character of the vaccine, and of course readily distinguished from it. " The first is a single pearl-coloured vesicle, set on a dark-red base, slightly elevated. It is larger and more globate than the pustule above represented, but much less than the genuine vesicle: its top is flattened, or sometimes a little depressed, but the margin is not rounded or prominent. " The second appears to be cellular, like the genuine vesicle; but is somewhat smaller, and more sessile, and has a sharp angulated edge. The scab is smaller and less regular than that which succeeds the gen- uine vesicle; it also falls off much sooner, and, when separated, leaves a smaller cic..tn\, which is sometimes angulated. Vol. 1.—27 210 CHICKEN-POX. " The third irregular appearance is a vesicle without an areola. The characteristics of a genuine vaccine pustule soon become familiar to the practitioner, and are not easily mistaken. But in doubtful cases the safest plan is, re-insert the vaccine virius in a short period after the first operation. The causes of spurious vaccination are various: the matter used may be itself spurious, or it may have lost its virtue by long keeping. But the most common cause of failure is the presence of cutaneous disease: and again, there are some children of perfectly healthy constitutions who are wholly unsusceptible to the vaccine influence. It is not to be denied, that the real small-pox has occasionally occurred in persons who have been to all appearance perfectly vaccin- ated; and a modified disease has been much noticed of latter years. But the former is extremely rare; and the latter, as will be elsewhere shown, is so much less severe than the variolous contagion, as to be a source of little apprehension. Some authors contend that the protection afforded by vaccination does not extend beyond seven, or at most twenty years. In some constitutions this is certainly the case, although it may not be so general a rule as many suppose. I have repeatedly vaccinated persons with the most unequivocal success, who had beyond all doubt gone through the same process from fifteen to twenty years before. In one family I saw five persons, the eldest not more than thirty, all of whom had been vaccinated in the most cautious manner in childhood; three of them in succession took the varioloid in a mild form, during which period the remaining two requested to be re-vac- cinated, which was done with entire success; the vesicles passed through their characteristic stages, and the patients escaped the dreaded contagion.] CHICKEN-POX. This disease, known also by the name of varicella, has been often confounded with small-pox. Those who maintain the identity of the two diseases, and who have figured in the controversy that has been so long carried on, have nevertheless completely failed in proving their position with respect to one point, while they have succeeded in * Bateman's Synop. p. 206. MILIARY FEVER. 211 another, apparently without being aware of it. Looking at the dis- eases symptomatically, there is no doubt a striking difference. The symptoms are all much slighter in chicken-pox; the eruption is vesi- cular, and there are repeated crops; and further, this disease is rarely attended with danger; but a pathological eye cannot fail to dis- cover a marked resemblance. The only questions to be determined are the following: Does an attack of the one disease prevent the other? Will matter taken from small-pox produce varicella, or from varicella small-pox? Extensive experience enables us to answer both in the negative, and therefore they cannot be identified any more than mea- sles or small-pox.* With respect to the treatment of varicella, it is only necessary to mention, that it must be conducted in the same manner with other slight eruptive fevers; and it should be remembered, that some local inflammation may arise even in the very slightest of them. I have known two fatal cases of varicella—one from inflammation of the sub- stance of the lungs in an adult, the other from inflammation of the membranes of the brain in a child eighteen months old. Since the publication of the first edition, I have been reminded of a third fatal case which occurred in 1825, in a child five months old. Traces of inflammation were found in the chest and abdomen. The head was not examined. MILIARY FEVER. This disease is characterized by an irregular eruption, of exceed- ingly small round vesicles of the size of millet seeds, and which feels, when the hand is passed over it, as if there were small grains of sand beneath the cuticle. Each vesicle is surrounded by a slight inflam- matory blush. This disease is said to be idiopathic, as well as symptomatic. There can be no doubt whatever, that an eruption of this character occasionally appears in the course of all fevers and inflammations; and in such cases, attention ought to be directed to the original dis- ease. It is also considered one of the diseases of child-bed. Since women in that state have been treated in a proper manner, by avoid- ing hot stimulating drinks, and by admitting cool air, it is not very * Vide Dr. Hennan's papers and experiments, in Ed. M. and S. Journal, vd. xiv. p. 109. 212 ROSEOLA. frequently met with. It is described by authors to commence with rigors, sickness, and languor, approaching to syncope, quick pulse, heat of skin, and thirst. The eruption does not usually appear till four, five, or six days after the commencement of the febrile attack. Previously to its appearance, there is a sense of pricking, tingling or itching of the skin, sometimes attended with a benumbed state of the extremities. The patient is greatly oppressed and complains of a sense of weight about the chest; the spirits are low, and a profuse perspiration takes place, which is frequently remarked to have a sour smell. At length the vesicles form into small scales, and fall off in a few days. The eruption is generally distinct, but sometimes confluent; it is said rarely to affect the face, and different crops may appear in the same fever; it attacks those most frequently, who have been previ- ously weakened by disease, fatigue, or long continued sweating, or who have had a hot regimen. The miliary vesicles often occur during the course of many of the puerperal diseases, such as milk fever, inflammation of the brain, and peritoneum. Mr. Burns, in his Principles of Midwifery, p. 420, says, " Whether the miliary fever be idiopathic or symptomatic, the treatment is the same." If he mean to state, that slight miliary eruption is to be treated in the same manner as miliary eruption " depending (to use his own expressions,) on fevers connected with a morbid state of the peritoneum or brain, which generally prove fatal," 1 cannot concur with him; as the eruption is to be regarded only as an accidental symptom of another disease. Treatment.—If this disease occur in the course of inflammation of the peritoneum, brain, &c. the particular disease ought to be treated in the proper manner, without reference to the eruption. If not, the bowels are to be regularly attended to; sweating is to be avoided, as well as every thing which heats the patient; and indigestible food must be prohibited. Whenever the patient is found perspiring, the linen should be changed in a careful manner, and the body properly dried and rubbed with a soft towel; in this case sulphuric acid will be found very useful, and there can be no objection to the moderate use of wine and bitters. ROSEOLA, Is a fever attended by a rose-coloured efflorescence, without wheals or papulae, and apparently not contagious. It has often been con- URTICARIA. 213 founded with measles and scarlet fever, and I have seen the wisest heads baffled in determining the point In one case in which such a division of opinion took place between two physicians, a third de- clared that the patient labored under small-pox; and the result of the case proved that his opinion was correct. This is a disease which may frequently be traced to indigestible matter, and particularly fruit, in the stomach and bowels; therefore the treatment is very simple—so simple, that even in the higher ranks medical men are seldom consulted; and they would probably be still less frequently called, only that parents are afraid that it is scarlet fever. Confinement, attention to the bowels, and avoiding solid animal food for a few days, are the best means which can be adopted. Willan and Bateman have given an account of seven varieties of this disease, but no practical benefit can be derived from such minute hair-breadth distinctions as these and other skin nosologists have drawn.* URTICARIA. This disease is known to the vulgar by the name of nettle-rash, and is distinguished from other febrile eruptions by circular elevations of the cuticle, of a red colour, with a white spot in the centre, and is usually termed a wheal; and here again Willan and Bateman have unnecessarily described six varieties. The eruption is generally preceded by marks, the most distinct, of gastro-intestinal irritation and fever; and the patient is affected with restlessness, oppression, languor, and want of appetite; his tongue, however foul, will in general be found red at the tip, and round the edges. If the eruption be very general, the patient suffers much dis- tress from the heat and itching of the parts, but the internal disorder will be found to be relieved. Sometimes the rash appears only when the individual is heated by exercise, or by wine, or when he is un- dressing himself; and it is also frequently excited in a fresh part by friction or scratching. This is an affection which is often produced by eating particular articles of food. * It affords me great pleasure to refer to Mr. Plumbe's Practical Treatise on Diseases of the !Skin. That gentleman has taken up correct views of the subject, and treats of all the affections pathologically : therefore he has few sub-divisions. It is the best work we possess on the subject. 214 THE PLAGUE. It appears to me, that individuals who are frequently subject to this affection, and others of a similar nature, during youth, are those who in after-life are affected with'gout It is sometimes difficult to distinguish urticaria from another very painful and troublesome affection, which is known by the name of erythema fugax; but this is a matter of no practical importance, as both eruptions are produced by the same causes, and cured by similar remedies. Urticaria may continue for an indefinite period, and may be repro- duced in particular constitutions every time the stomach is disordered. Treatment.—Nothing is more simple than the management of a case of urticaria; but much more depends upon the patient himself, than upon the remedies which a physician may prescribe. The pa- tient must find out, by experience, the articles of food which disagree with him, and he must have sufficient resolution to avoid them for a time. It should be impressed upon young practitioners, that danger sometimes proceeds from the repulsion of the eruption by cosmetics. A very beautiful young lady was frequently troubled with febrile symptoms and this rash. She was attended by an eminent physician, who gave her a large bottle of a strong solution of sugar of lead, with directions to sponge her body with the wash when her skin was very itchy. Upon the first occasion, she stripped herself, and applied it as extensively as she could, and it surprised her that the itching suddenly ceased; upon examination, the eruption, which was very vivid before, had now almost entirely disappeared. She instantly felt sick, oppress- ed, and fainted; and continued for such a considerable time in a state of insensibility, that her attendants were doubtful of her recoverv. She survived, but has not since known what it is to enjoy a day's good health. Besides avoiding every thing that disagrees with a patient, it may be mentioned that gentle laxatives are essential remedies: and that an eme- tic is highly useful, if any indigestible matter be still in the stomach. THE PLAGUE. The disease which is now to be shortly described, appears to be an endemic fever, attended during its course by buboes, carbuncles, or some eruption on the surface of the body. It is, under certain circum- stances and seasons, highly contagious; and it would seem also to be occasionally epidemic. . THE PLAGUE. 215 The accounts we have of the phenomena of this disease are so contradictory, and the history of morbid appearances are so few and meagre, that I have not sufficient data before me wherewith to form pathological descriptions. The plague, it would appear, is sometimes very mild, at others very severe; and if it be a fever, of which I have now no doubt,* the symp- toms must not only vary in intensity, but they must also have a very wide range of character. It must have varieties and shades arising out of one organ being more severely affected than another, as well as from local congestions and inflammations. The plague appears to be modi- • fied also by season, situation, and habits of individuals. It is not to be wondered at, therefore, that different writers should have given different histories of the symptoms and progress of this disease; but as yet, we have no pathological description that can be depended on; therefore, my observations must be brief. It seems to be the general opinion, that the plague is nothing more than a malignant typhus, and the only peculiar symptom that has been described is the bubo, carbuncle, or the appearance of some eruption on the surface of the body; and all writers agree in opinion, that the safety of the patient very much depends upon the suppuration going on speedily and kindly. The plague, therefore, seems to be closely allied to the exanthemata, and more particularly to small-pox. The disease appears to be ushered in by rigors and oppression, fol- lowed by heat of skin, great prostration of strength, giddiness, and headache; the expression of the countenance is besotted, and the eyes have a muddy, glistening appearance. It is stated, however, that in some cases there is a ferocious aspect: in others, the patient's look is subdued. The pulse varies much; it is sometimes quick and full, at others,quick and small; sometimes described as being hard, at others, soft The intellect is sometimes clouded; at others, there is insensi- bility and fierce delirium; occasionally stupor takes place, and in some cases the functions of the brain remain distinct and clear. The patient, in general, seems indifferent respecting his fate; the tongue is at first moist, although it may be more or less loaded; there is some- times constipation, at others diarrhoea; the stools are always highly offensive; the stomach is in general very irritable, every thing taken being almost instantly rejected. * 1 have had the pleasure of enjoying several communications with Dr. M'Guf- fuc, who resided many years in Turkey, and who has seen the disease. It is his decided opinion, that the plague is a fever attended by buboes, &c. 216 THE PLAGUE. In a few days from the first attack, generally the third, pains, often acute, are complained of in the groins and arm-pits; and unless the swelling and suppuration of the glands go on quickly, death soon takes place. Sometimes carbuncles appear with or without the buboes; nut petechiae more frequently than carbuncles. Discharges of blood from the stomach and intestines often take place in the last stage. Some- times the disease is very rapid in its progress—frequently it runs its ' course in thirty hours. It is said that if the patient survives the fifth day, the bubo being completely formed, he may be pronounced to be doing well, if not actually out of danger. As in the acute eruptive diseases, there are two periods fraught with greater danger than others, # viz., that at which the bubo makes, or ought to make, its appearance, and that at which it ought to be matured. The convalescence, as in all severe fevers, is very slow, which is attributed to the extremely debilitated state in which the patient is left; but there can be little doubt that a great deal is generally owing to bad nursing, and want, perhaps, of sufficient comforts. It is a curious and interesting fact, that Sir James M'Grigor and Sir John Webb, the former the director-general of the medical depart- ment of the army, the latter director of the medical department of the ordnance, should have distinguished themselves in the same field of investigation, having been both employed with our Egyptian army thirty*years ago, when they displayed that talent, zeal and humanity in the performance of their duties, which endeared them to all who were placed under their care. It was there these distinguished per- sons gave evidence of the great powers of mind and regular habits of business, which marked them out as men admirably qualified for the high situations in which they have been subsequently placed, and which they have filled with so much honour to themselves, and bene- fit to the service. Their statements respecting the plague, will be read with much interest and advantage.* Treatment.—Sydenham recommended free and 'repeated venesec- tion in this disease, during what may be called the eruptive fever, and it has occasionally been practised since his time; but even Sydenham himself seemed latterly to prefer sweating the patient, under the idea of withdrawing the pestilence in that way from the body, which weak- ened him less than blood-letting. Some individuals condemn bleed- ing entirely. The same difference exists with regard to purging. * Sir James M'C.rigor's Medical Sketches of the Expedition from India to Egypt. Sir John Webb's Narrative, Gth vol. .Medical Transactions. THE PLAGUE. 217 Cullen condemns both, but recommends the violence of re-action to be moderated, as far as it can be done, uby taking off the spasm of the extreme vessels." The application of oil to the surface of the body is believed to be a preservative, and it has also been employed to cure the disease; but even upon these points, such opposite state- ments have been promulgated, that we have no means of forming cor- rect opinions. A great number of other remedies have been strongly recommended, as mercury, wine and bark, camphor, opium and aether, emetics, diaphoretics, and the cold affusion; and if my notions of the disease be at all correct, there are cases and stages in which several of these remedies, if not all of them, may prove highly beneficial; but there are others in which they must have the very opposite effect. For example, if there be violent inflammation and congestion of the brain, no one will say that wine, aether, bark, or camphor, are the proper remedies; but in which cold applications to the head, and the action of mercury, might be beneficial. In the last stage of the dis- ease, the lancet would be most improper, when wine, aether, opium, and even brandy itself, may snatch the person from the grave. If the stomach be irritable, which it almost always is in this disease, no one, I hope, would think of making it more so by exhibiting emetics and large doses of bark. It is to be feared that the recommendation and condemnation of various important remedies have taken place, with- out reference to the stage of the disease, the particular organ or organs affected, the peculiarities of the prevailing distemper, as well as the idiosyncracy of the patient; but it becomes me to speak with diffi- dence upon a subject, with which I must acknowledge myself to be very imperfectly acquainted. The reader who wishes for more minute information, must peruse the various works published upon this subject; or a most excellent abstract of them, in the 3d volume of Dr. Mason Good's Study of Medicine. The chapter on the plague appears to me to be the most meritorious part of his work. Vol. I.—28 PART II. DISEASES OF THE ORGANS CONNECTED WITH THE DIGESTIVE SYSTEM. CHAPTER I. DIFFICULT DENTITION. Few children go through the process of dentition without some suffering; and when teething is difficult, a variety of complaints arise, which come under the denomination of infantile diseases. These are fever, determination to the head, convulsions, cough, bowel com- plaints, cutaneous and glandular affections, inflammation of the eyes, and soreness behind the ears. Authors have long remarked, that children who teethe at an early period, have least suffering; and the same observation has been made with respect to those who have a considerable flow of saliva. There have been instances of children born with teeth, which happened, it is said, to Richard III. and Lewis XIV.; and Haller has cited a con- siderable number of similar cases. Some infants cut the first pair of teeth by the end of the third month; in other instances, not until they are sixteen or eighteen months old. In general, however, they are cut between the sixth and eighth months. The two centre incisors of the lower jaw com- monly appear first; in the course of a month, their opponents in the upper jaw protrude; after this, the two lateral incisors of the lower, and then those of the upper jaw, appear. Between the twelfth and sixteenth month, the anterior grinders of the lower, and then those of the upper jaw are cut; subsequently the cuspidati or eye-teeth pro- trude, and after these the posterior grinders; so that children usually have the first set of teeth (twenty in number) complete by the time they have attained the age of two years, or two and a half. There are generally intervals of several weeks between the cutting of each pair. The formation of each tooth goes on in a membranous and vascular sac which is firmly united to the gum; and if we attempt to tear the gum from the jaw, the sac is brought along with it. This sac, it would appear, subsequently becomes absorbed; but when it is thicker 222 DIFFICULT DENTITION. than usual, more vascular, and long of being absorbed, it is one of the alleged causes of difficult dentition. The irritation produced by the pressure of each tooth against the gum in its advancement to the sur- face, particularly when the child teethes late, and the gums are hard and cartilaginous, also occasions the different phenomena which are ranked under the name of difficult dentition. A child under such circumstances is observed to be restless, fretful, and feverish; to sleep little, and is often seized with sudden fits of screaming. The bowels are out of order, and the evacuations fetid. On some occasions, marks of determination of blood towards the head take place, viz. great restlessness, flushed face, sudden fits of crying, apparent suffering when brought into the erect posture, starl- ings, slight spasmodic movements of the muscles of the face, and even general convulsions. Many children, whenever they cut a tooth, are teazed with a cough, depending on bronchitic irritation or inflammation. This is announced by wheezing. Others suffer from constipation, while many are afflicted with troublesome diarrhoea. Cutaneous and glandular affections are often observed during difficult dentition. The glands of the neck, and the sub-maxillary, are those generally affected, and they sometimes suppurate. Of the eruptions, the herpes larvalis and lichen are those most commonly seen. Occasionally there is inflammation of the eyes, particularly that form which is termed ophthalmia purulenta; and sores take place behind the ears, which seem to operate beneficially. This statement will show the propriety of examining the mouth, when we are called to a child labouring under these, or any other affections, during the period of dentition; and it may be well to mention here, the appear- ances the gums will present under such circumstances. The mouth may be very hot, and on examining the gum over the tooth which we suspect, it will be found to be elevated, very red, sometimes white and shining: the ridge or seam, which runs along the jaw in the di- rection of the teeth, will in general be found to have disappeared. Under such circumstances, the tooth may be pronounced to be far advanced; at all events, it is well to be able to say whether it be near at hand or not, as mothers are often disappointed if the tooth over which the gum is cut, does not show itself in a day or two; whereas, if they are told beforehand that it is not so near, they will in general I be satisfied. The best remedy is, to divide the gum, down to the ( very tooth, by crucial incisions. Many people entertain a dislike to this operation, from the idea that the gum is hardened by the cicatrix; DIFFICULT DENTITION. 223 but they may be safely assured that this is not the case, and that the tooth will be advanced, certainly not retarded, by the scarification. If the operation be effectually performed, it constitutes the principal part of the treatment; should the gum even heal immediately, the bleeding will remove the local inflammation, upon which the febrile symptoms frequently subside. The bowels must be kept freely open, and the tepid bath is often of great service. If the face be flushed with other marks of determination to the head, the application of cold may be tried, the child should at least sleep without its cap, and use a hard pillow; frequently have I seen it advantageous to change a down pillow for one filled with fine shavings. It is probable that some of the serious affections of the brain to which children are liable, may be attributed to warm caps and soft pillows. The bowels must be more freely acted upon; and if these means do not succeed, it will be well to apply leeches to the feet, which may be subsequently placed in warm water, for the purpose of encouraging the bleeding; besides which, the haemorrhage is better under command upon the application of a bandage. Many practitioners are heard to complain of the great difficulty in stopping the bleeding in young children, but 1 never ex- perienced any myself. In the first place, we ought always to point out the situation where the leeches are to be applied, which I take care shall be, if possible, over a bone, against which pressure can be applied. Secondly, not to apply too many at a time: it is rare to find more than one orifice troublesome, from which the bleeding will be easily suppressed, by gently pinching the skin between the finger and thumb for a few minutes. I have never been obliged to use the actual cautery, or even caustic. We are often not called, however, till convulsions have actually taken place, which are to be treated in the manner to be subsequently described in the 2d volume. I may, however, mention here, that the child should be put into a warm bath as soon as possible; the face sprinkled with cold water; and if a fit should continue long, and threaten danger, a vein should be opened on the instant Should the external jugular be readily observed, blood may be drawn from it; but if a vein cannot be found, the hot bath and stimulating frictions must be trusted to, till leeches are obtained. Great attention should be paid to keep up a brisk action in the bowels, by means of suitable doses of calomel and jalap, or calomel combined with rhubarb or scam- mony, together with castor oil and injections; but all these means will be of no avail unless the gums be freely scarified. Cough is occasionally a troublesome attendant on teething, and prac- 224 DIFFICULT DENTITION. titioners will be found, in general, to act empirically, unless they are able to ascertain whether it depend upon any diseased action in the lungs, or merely upon irritation about the epiglottis and pharynx. If the latter, a common cough mixture may do good; but it will be inef- ficacious, perhaps injurious, if the cough proceed from bronchitis, which may sometimes require the application of leeches or of a blister, or counter-irritation produced by a mustard plaster, or the ointment of tartar emetic. If the lungs be very much loaded with mucus, which is easily ascertained, an emetic will be very serviceable; but the treat- ment of bronchitis need not be dwelt upon in this place. It is only necessary to state the general principles, with reference to the affection now under consideration. When a child, who is suffering from difficult dentition, has diar- rhoea, we should not be in a hurry to check it, particularly if there be marks of determination to the head. The bowel complaints of children are of so much importance, that it is necessary tb treat of 1 hem in a separate article, with a view to point out their pathology; but it must be mentioned in this place, that the best practice is to exhibit a little castor oil in the first instance; and if there be any pain in the ab- domen, warm fomentations are to be used; should there still be signs of suffering, a leech or two may be applied, followed by very small doses of Dover's powder, or a drop or two of Battley's sedative solu- tion of opium. It is very fortunate that children, upon the occurrence of the most trifling febrile symptoms, or disorder of the bowels, are liable to erup- tion on the surface, because they act beneficially by removing irritation and increased action, on many occasions inflammation itself, from inter- nal organs. When these eruptions take place during the course of denti- tion, it will almost always be found best not to meddle farther with them than to enjoin cleanliness; indeed, on many occasions, do what we will, the eruption continues, the child becoming better between the periods of cutting teeth. I have frequently seen great mischief done when external applications had the effect of repelling the eruption, and on more than one occasion death itself. In "porrigo larvalis," when there is great heat, itching, and inflammation of the part, I have found it answer well to apply leeches to the inflamed surface. The child's hands should be muffled, to prevent the face from being scratched., Glandular affections may be safely let alone, unless they become inflamed and painful, when the practitioner will do well to apply either leeches or a soft warm poultice. If matter forms, the sooner it is let out the better, in whatever constitution it may occur, there being far more DIFFICULT DENTITION. 22 f) danger of leaving a disagreeable mark, by allowing the pus to discharge itself spontaneously, than by using the lancet. We are often consulted respecting inflammation of the eyes at this period of life. Generally speaking, the disease will be found to be confined to the conjunctiva; sometimes to the tarsi; there is rarely- deep-seated inflammation of the eye itself. A leech or two applied to the temple, is always safe practice, as well as a blister behind the ear: indeed nature points this out, by the relief which supervenes, upon a natural sore appearing in that situation. Let me add, that whenever we have occasion to blister a child, we should be careful that none of the powder of cantharides is sprinkled upon the surface of the plaster, which frequently creates unnecessary irritation; and above all, the blistered surface should be carefully examined every day by the medical attendant, till it shows a healing tendency, as it is apt to slough, which the timely application of a linseed poultice will very frequently check. With respect to the natural ulcerations that take place behind the ears, it is only necessary to use frequent ablution with warm milk and water, and to take care that they are not unnecessarily irritated. Great uneasiness is often produced by carelessly removing the dressings; this might always be avoided by previously applying tepid fomentations. Under all the circumstances which have been mentioned, an oc- casional opiate is very beneficial; but no medicine of this kind should be left in the way of an ordinary nurse, who will often administer it to secure to herself a quiet night, to the great injury of the child: even Dalby's carminative, or syrup of poppies, should never be left in the nursery. I have known many children destroyed by their con- stant exhibition. The American soothing syrup is another remedy- that is perhaps too frequently ordered by medical men: it is supposed to soften the gums, and to render the process of teething easier; which it does, not by mollifying the gums, but by virtue of a narcotic princi- ple which it contains. A child, when teething, carries every thing to its mouth, bites it, and thereby seems to experience relief, and nothing will be found to please it more than the nurse rubbing the gums with her finger. A gum- stick promotes the flow of saliva, and amuses the infant Vol [. — ■»> CHAPTER II. DIFFICULT DEGLUTITION FROM INFLAMMATION, UL- CERATION, OR ENLARGEMENT OF THE TONGUE; CYNANCHE TONSILLARIS; CYNANCHE PHARYNGEA; INFLAMMATION OR ULCERATION OF THE OESOPHA- GUS. Difficult deglutition may be produced by inflammation, ulceration, or enlargement of the tongue; which are often caused by the action of mercury and other metallic poisons. If the affection be produced by mercury, leeches applied to the cheeks are said to be very useful, as also a wash composed of a solution of the chlorate of soda, or that of lime. Several serious cases of inflammation of the tongue have lately been published. Two will be found in the 92d and 93d Nos. of the Edinburgh Journal, and a fatal one in the 214th No. of the Lancet If I can trust my own observations, I am inclined to believe that inflammation and enlargement of the tongue are generally owing to some temporary diseased action in the chylo-poietic viscera. I nfay appeal to the experience of any professional man, who is liable to derangements of the stomach and bowels, whether he has not, on such occasions, felt his tongue sometimes swollen and painful, and even slightly ulcerated in different parts of the tip and edges; and whether he has not been led to attribute such a condition to the state of his digestive organs. Whether this view be correct to the full extent or not, the stomach and bowels must be attended to in the treatment. Children in particular are very liable to white specks, vesicles, or ulcerations on the tongue, and over all the mucous memi>rane of the mouth and fauces. These specks are called aphthae. We meet with this affection in two forms, one of which is mild, the other very severe. In the first, the treatment consists in keeping the bowels gently open, avoiding solid food, and using the warm bath. In the last, I feel per- suaded, from the vomiting and purging, and the intensity of the other symptoms, that the disease affects considerable portions of the intes- CYNANCHE TONSILLARIS. 227 tinal tube, and requires a different plan. Before the appearance of the ulcerations in the mouth, the constitutional symptoms occasionally run high, which are sometimes relieved upon the mouth becoming sore; so that this affection has some resemblance to the exanthemata. Mr. Burns, in describing this disease, states, that " the child is some- times drowsy, and oppressed for some hours, or even a day or two, before the spots appear, and occasionally is affected with spasms. The fever and oppression are often mitigated on the appearance of the aphthae." Children affected in this manner, suffer great pain, and are consequently exceedingly peevish. The stools are generally acrid, sour, and discoloured; there are often tenesmus, and prolapsus ani, and the surface around the anus is excoriated. Successive crops of aphthae appear, which resemble small portions of curdled milk adhering to different parts of the tongue and mouth; after a time they become yellow, and seem to slough off, but may be renewed many times. When they drop off, the parts below frequently look raw, particularly in severe cases, in which the crust sometimes becomes dry and hard; occasionally the parts look very foul, dark-coloured, and have a fetid smell. A case of an adult lately fell under my observa- tion, in which great suffering was produced; the sloughs were most extensive, and portions even of the palate itself were thrown off. The diseased action frequently extends into the air passages, an- nounced by dyspnoea and cough. Children brought up by the spoon, are more liable to apthus affection than others, as well as those whose bowels are neglected, or are insufficiently clothed> Treatment.—This pathological description, 6t the disease leads at once to the proper mode of practice. . In the two causes of inflamma- tion of the tongue recorded in the .Edinburgh Medical and Surgical Journal, venesection and the application of leeches, produced tempo- rary benefit only, while deep scarifications were had recourse to with permanent advantage. It is probable,'however, that sufficient atten- tion has not been always paid to the condition 6*T the stomach and bowels. With respect to the severe cases of apthous affections of the tongue and mouth, 1 can speak strongly qf the advantages derived from the frequent application of leeches to the abdomen, if the strength be good, the warm bath, and counter-irritation on the abdomen by means of a stimulating embrocation, or the tartar-emetic ointment. The contents of the bowels should be discharged by an occasional dose of castor oil. An injection, composed of a few drops of laudanum, and a table spoon- ful of starch or gruel, may he thrown into the rectum, by means of a 228 CYNANCHE TONSILLARIS. small penis syringe; but it is difficult at all times to make a child re- tain it Dover's powder, united with aromatic powder, is also a good remedy. If a child upon the breast be affected in this manner, no other food should be allowed; if it be already weaned,ass' milk ought to be pro- vided; bat if it cannot be procured, whey mixed with a little cream, and occasionally a little thin gruel, may be substituted; beef tea, and soups of all kinds, are, according to my own experience, bad, until the disease be far upon the decline; if the child's strength be sinking, wine, properly diluted, is far less exceptionable than soups or animal jellies. A weak solution of the chlorate of soda, combined with an opiate, will be found serviceable—a tea-spoonful for a dose.: Consider- able mischief is sometimes done, and children are very much and unnecessarily fretted, by the application of borax and sugar introduced into the mouth upon a cloth, or a finger, and rubbed so as to remove the crusts. CYNANCHK TONSILLARIS. There are two varieties in this affection, the acute and chronic. In the acute, the swallowing is difficult and painful; the voice is altered, and in very severe cases the respiration is impeded; the pain, gene- rally speaking, is^severf. On looking into the throat, ihe tonsils, uvula, and even part of the* palate, are seen much swollen, and very vascular, and sometimes the throat is swollen externally. Loss of appetite, thirst, headache, and general fever, for the most part, accompany this disease; occasionally these symptoms run high, and there is delirium. In some cases only one tonsil is inflamed; in others, the uvula only; sometimes white specks are seen upon the inflamed part, surrounded by a viscid exudation, which present the appearance of ulcerations. The white specks alluded to, are sometimes produced by exudations of lymph, at others, by sebaceous matter making its escape from the mucous follicles. It has often been in my power to prove, that the sebaceous matter is one cause of a 'frbad breath."' This form of sore- throat bears a considerable resemblance to the cutaneous affection termed acne. Occasionally, however, ulcerations are observed in the throat. Cynanche tonsillaris terminates in resolution; sometimes in suppu- ration, ulceration, and sloughing. When matter forms, the patient's sufferings are generally increased, the dyspnoea is considerable, and he is said, in common language, to have a quinsy. CYNANCHE TONSILLARIS. 229 The most frequent cause of this complaint is supposed to be cold, produced by sudden vicissitudes of weather; but I imagine there is a combination of causes in the production of inflammation of the throat, and that the principal are a disordered state of the stomach and bowels, and the formation of the sebaceous matter above alluded to. Many individuals are known to me, who never have a sore throat, unless the stomach and bowels have been for some time out of order; as well as others, who for a series of years have escaped an attack by regulating themselves properly in this respect. Treatment.—This complaint is sometimes very little under the power of the usual remedies, unless it be attacked at the very begin- ning;, and it is only in such cases, or to check the inflammation from running into extensive ulceration or sloughing, that venesection ought to be had recourse to. Leeches may be applied externally, under similar restrictions. It has been recommended, that they should be applied internally to the part immediately affected; in which last case, each leech is introduced by means of a tube, with a thread through the tail; but when it is thought necessary to draw blood from the part more immediately affected, it is much more easily and speedily done by scarifications, and much less painful to the patient. Blisters are very frequently useful. Females have a great objection both to leeches and blisters; but particularly to the former, from the marks they pro- duce. Laxative medicines are highly necessary, and must be fre- quently repeated. Emetics are much extolled. The best gargle, if it be necessary to wash the throat, is a little warm water, or acidulated infusion of roses. Inhaling the vapour of hot water is productive of great benefit, whether suppuration is to take place or not. When matter forms, dyspnoea frequently becomes a marked symptom; there- fore the sooner it is discharged the better for the patient; and it is by no means a painful operation, the relief being often instantaneous. Several fatal cases have come to my knowledge, although 1 have not seen one myself; it is strongly suspected, however, that the imme- diate cause of death has been inflammation extending into the larynx and bronchial tubes. Chronic cynanche tonsillaris may be either the consequence of acute inflammation terminating in the chronic state, or may take place as the effect of sub-acute inflammatory action; the uvula is found en- larged and hard, as arc the tonsils. If the case be recent, stimulating applications are found useful, and a succession of blisters to the throat; if these means do not succeed, and the enlargement is permanent, par- ticularly if the voice be affected, the patient becomes an object of sur- gical treatment. 230 INFLAMMATION OF THE PHARYNX. Sometimes extensive and troublesome ulcerations are produced, as the effects of chronic, as well as of acute inflammation in the throat; and in treating these, it is necessary in the first place to attend to the general health, by regulating the state of the stomach and bowels, and also the diet, which ought to consist of mild and digestible substances. Leeches and blisters are often serviceable; but the most efficacious application, is a solution of the nitrate of silver in distilled water, in the proportion of four, six, and even ten grains to the ounce. The ulcerated surface is to be carefully washed before the solution is ap- plied. This operation, however insignificant it may appear, must be done with proper care, as bad consequences have been known to fol- low. There is a preparation in my museum, in which the epiglottis is completely destroyed by common caustic, rudely used. INFLAMMATION OF THE PHARYNX. In this affection the tonsils and uvula are not invariably inflamed; but upon looking, the parts being exposed to a bright light, we can often see the throat and pharynx very vascular, and loaded with viscid lymph, which the patient is constantly making efforts to dislodge by hawking and spitting. The pain on swallowing is fully greater than in the last described affection. I have seen patients suffering severely, some apparently in great danger. When it is severe, the lancet must be used, followed or not by the application of leeches and blisters, according to circum- stances. The inhalation of the vapour of hot water affords remark- able mitigation of the symptoms, and in slight cases, nothing further is required but to keep the bowels open, and allowing moderate nour- ishment [Chronic pharyngitis, accompanied by extensive ulceration, has be- come very common in the United States. The ulcers are most fre- quent on that part of the mucous membrane which covers the spine: they also form about the base of the tonsils, and less frequently on the anterior surface of the soft palate. They put on every appearance from mere denudation of the membrane, to ragged, dark, and livid ulcers. I have sometimes seen the whole pharynx involved in the disease, presenting a raw, unequal surface throughout Occasionally it yields to the mere use of astringent gargles, especially of the dilu- ted creosote solution, or a strong infusion of black-oak bark. But in other instances they resist every form of treatment except that by INFLAMMATION AND ULCERATION OF THE OESOPHAGUS. 231 lunar caustic, which is best applied in solution, (4 grs. to the ounce of water) by means of a camel's-hair brush. This operation, to be successful, must in most cases be several, and perhaps many times re- peated, not omitting, however, the assiduous use of gargles. When the ulcers have fairly skinned over, they are liable to re- appear on taking cold; so that the disease becomes tenacious and exci- table on some persons, harassing them, at intervals, for years, occa- sioning much local distress and even altering the voice.] INFLAMMATION AND ULCERATION OF THE OESOPHAGUS. Of all the structures in the human body, the oesophagus is perhaps the least liable to disease. In general it is difficult to detect inflam- mation of the oesophagus till ulceration and constriction take place. I have seen only one case of universal inflammation of this tube not caused by poison, in which the lining membrane was in a sloughing state. There is a preparation in my museum that displays similar appearances; in this case, however, there were no symptoms indica- cative of disease in the tube. In the former case which I attended, there was pain and difficulty in swallowing. Both patients were also affected with phthisis. Inflammation may be partial, affecting only a part of the calibre of the oesophagus; and if ulceration follow, there will be no contraction, but the patient will feel slight pain and a mo- mentary stoppage when the bolus of food arrives at the spot. If the whole calibre of the oesophagus be involved in the inflammation, the pain will be more considerable, not so much from constriction as from the effort to vomit, which is produced by irritation. If it terminates in ulceration, occupying the whole tube, constriction will take place, with increased difficulty in swallowing. Patients have been known to be three and four days, and even a week, without food. Treatment.—Attention to the bowels, topical bleeding, and exten- sive counter irritation, are the best means which can be employed. Nourishing injections thrown into the rectum, are to be assiduously administered when the patient is unable to swallow a sufficient quan- tity of food. It is the practice in such cases to introduce instruments into the oesophagus, to produce dilatation; but I have seen it very in- jurious in several instances, when the operation was performed during the inflammatory stage. Affecting the system with mercury has been hi»hly extolled without sufficient consideration. If the constriction be permanent, after the inflammation and irritation are subdued, a stir- 232 CHRONIC AFFECTIONS OF THE (ESOPHAGUS. geon may be called to make cautious trials with a bougie; perhaps an oesophagus tube will be found the best instrument for this purpose. CHRONIC AFFECTIONS OF THE CESOPHAGUS. Sometimes the gullet is diminished in diameter by fleshy excres- cences, tumours, or occasionally scirrhous contractions are observed; and more rarely, ossification. Some individuals have survived contrac- tions of the oesophagus for a great many years, being obliged to have food introduced into the stomach through a tube. Chronic diseases of the oesophagus are frequently found to have made considerable pro- gress before their existence is even suspected. The smoke of tobacco and stramonium, the abuse of mercury, and drinking fluids either excessively hot or cold, have been assigned by writers as the general causes, but perhaps too hastily. Of all the remedies which have been recommended to us in such cases, the bougie is undoubtedly the best; and if at any time there should be much pain, leeching, counter-irritation, and narcotics, are to be had recourse to. Many other circumstances produce difficulty in swallowing, as for instance, want of the uvula, tumour in the pharynx, ulcerations in the larynx, or upon the epiglottis. The first two belong more to the sur- gical department than the medical, and therefore cannot be treated of in this work; the last two shall be noticed among the diseases of the respiratory organs. CHAPTER III. INDIGESTION. Under this head I shall treat of the affection which is commonly called dyspepsia, with its usual attendants, flatulency, tympanitis, heart- burn, and pyrosis; and also of the painful affection termed gastrodynia. Dyspepsia is a most troublesome disease to treat; and I believe the physician, to be able to do so effectually, should have suffered from it himself; as one who has had the good fortune never to feel as if he had a stomach, can scarcely believe, or hardly listen to, the complaints of those who have experienced that sensation. One symptom is more prominent and urgent in one case than another; a little flatus in the stomach occasionally produces violent nervous symptoms, sometimes as if the brain were seriously affected; and the whole will vanish after one or two sour eructations. Some patients appear as if they could not survive the difficulty of breathing under which they labour; and it will be found to depend, perhaps, on flatus rising in the oesophagus, producing the affection called globus hystericus. Remedies have not the same effect in any two cases; all plans of treatment will most ge- nerally fail, unless the patient himself can discover what articles of food agree with him better than others, and has resolution enough to adhere to a proper regimen. Dyspepsia may arise from various causes: first, from simple functional derangement of the stomach, duodenum, liver, spleen, or pancreas; secondly, from indigestible and acrid substances taken into the stomach; thirdly, from structural de- rangements in the digestive apparatus; fourthly, from long continued constipation; fifthly, from derangements in other important organs. Dr. Wilson Philip, who has written an excellent work upon this subject, has divided the disease into three stages. This plan would do admirably well, if dyspepsia were as regular in its march as intermittent fever; but in practice, such an arbitrary arrangement will not be found useful, because the second, or even the third stage may be produced at once, without advancing regularly through the others. First staqe of Indigestion.—The first symptoms of indigestion Vol. I.—SO 234 INDIGESTION. area sense of fulness and uneasiness in the region of the stomach, arising either from too great a load of food, from some indigestible ar- ticle, or from flatulent distension of the stomach; frequent acid eruc- tations, constipation, loaded tongue, and some thirst, follow. Some- times sore throat is complained of; it is difficult to keep the hands and feet in a sufficient degree of heat; and occasionally there« is severe headache. These symptoms may steal on slowly, and from being felt only oc- casionally, are neglected; or they may be produced suddenly, by in- dulgence in a copious draught of very cold water, or from anxiety, grief, fright, or other severe mental affections, or by too violent exer- cise after a full meal. Physicians are rarely consulted in the first stage of the complaint; for the patient either drives on through it, or relieves himself by a day or two's abstinence, and by taking a laxative. If a person, how- ever, take little heed of himself, he is soon heard to complain of rest- less nights, oppression at the praecordia, and becomes sensible of di- minution of strength, and heat of skin; his appetite becomes fastidi- ous; he is either very costive, or is affected with diarrhoea. Thealvine discharge is sometimes very bilious; at others white, showing a want of bile; it is sticky, drops with difficulty from the body, and is very fetid. After the patient obtains passage from the bowels, he still feels much loaded, and very often considerable quantities of half-digested food will be observed in the stools. Persons labouring under such symptoms, will very generally be heard to attribute their complaint to a "fit of the bile;" and many medical men, I fear, confound stomach disorders with those of the liver, and too frequently exhibit powerful mercurial preparations, to the great injury of the patient. Treatment of the first stage.—The cure of this form of the com- plaint is not difficult. The patient is to be directed to abstain from the use of soups,and whatever else distends the stomach; to eat little, and to leave off while he has still an appetite; to keep his bowels open with a little rhubarb, Henry's calcined magnesia, or a compound colo- cynth pill; and to take regular exercise. He should, as much as pos- sible, avoid any cause which has a tendency to produce mental excite- ment or depression. The second stage of dyspepsia is marked, according to Dr. Wilson Philip, by the supervention of tenderness in the epigastric region, and a hard pulse; and he very justly considers these two symptoms of much practical importance. The patient now feels very sensible IND1CESTION. 23."> to the impression of cold; he is often chilly, and afterwards complains of flushes of heat; his hands and feet have sometimes a dry, burning sensation, particularly during the first part of the night, extremely cold at other periods, painfully so when he first goes to bed; his skin becomes hot in bad cases, towards morning a perspiration breaks out, and the patient enjoys some quiet sleep. When he awakes, although he may complain of not feeling refreshed, yet the symptoms are greatly relieved. His debility is now greater, with some emaciation; he com- plains of languor, and always desponds. There is considerable un- easiness and fulness in the epigastric region, and an occasional darting pain towards the spine, together with a burning sensation in the sto- mach. Palpitations are now, perhaps, very troublesome;t hey are not constant, however, but become worse after dinner; the least thing agi- tates the mind, and produces them. The patient sometimes coughs and expectorates in the morning, and supposes he is consumptive; or there is vertigo and headache, with imperfect vision, as, for instance, seeing two objects instead of one, or only half an object, and it is im- possible to persuade him that he is not threatened with apoplexy. In cases of dyspepsia, some individuals, particularly those with light hair, are very liable to inflammation of the tarsi, with purulent exudation; and sometimes little abscesses form, which are called in common language " styes." The kidneys frequently suffer, the flow of urine being either too sparing or too copious, attended with com- plaints which are called " gravellish." It is my belief that dyspeptics are more liable than others to inveterate skin diseases, and to stone in the bladder. It will be found also that most of the individuals who labour under hoemorrhoidal affections are dyspeptics; and it may be mentioned, that I have rarely seen a person afflicted with fistula in ano, excepting when it proceeded from external injury, who has not been a martyr for a long period to this class of complaints. Pure surgeons should make themselves acquainted with these facts, and a great many other points of medical pathology. It is rare to see all these complications, but they are occasionally met with in the same patient. 1 have seen many patients consider their lives as burdens to themselves, and there is often a strong ten- dency to commit suicide. Should the symptoms continue severe for a considerable time, some serious organic lesion may be dreaded; but the lungs, liver, and brain, are the organs which most frequently suffer, and form \v*at may be termed the third stage of dyspepsia. # Treatment of the second sta^e.—Whenever the patient complains 236 INDIGESTION. of tenderness in the epigastric region, with a hard pulse and bad nights, local bleeding by cupping or leeching frequently produces the best effects. My own plan, in severe cases, is to apply leeches, to the number of twelve or eighteen, two or three times if necessary, before counter-irritation is had recourse to; and the best method of producing irritation, is by frictions with the tartrate of antimony oint- ment, which must be persevered in, first on one part, then on another, so as to produce a succession of pustules. 1 have been led to place much dependence on this practice, by observing that dyspeptics have sometimes been relieved, at others cured, upon the appearance of a spontaneous eruption. In severe cases, the diet should consist of gruel, arrowroot, milk, calf-foot jelly, light pudding, and good bread; and these should be allowed in limited quantity; more than a breakfast tea-cupful at a time will overload the stomach. Soups and vegetables should be avoided, at least for some time. Gentle laxatives, so as to open the bowels twice a-day, are to be used. The tepid bath will be found very useful; but perspiration must not be encouraged after com- ing out of the bath. The patient should be clad according to the sea- son of the year; and it is of great consequence to keep the feet com- fortably warm and dry; in order to insure this, worsted stockings are too frequently directed to be worn, which, in many individuals, will produce the very circumstance it is wished to avoid. It was a long time before I could discover the cause of this; and I believe I may now state confidently, that worsted stockings, worn by people whose feet perspire, will tend to produce coldness of the extremities; under such circumstances, I find the object is attained, if the patient wear an under stocking either of silk or thin cotton. Exercise in the open air is highly necessary as soon as the patient's strength will permit: if he ride on horseback, the feet should be additionally protected in cold weather by mud or cloth boots, and he should never make use of horse exercise for two or three hours after a meal. By degrees, he may be allowed a small tea-cup full of chicken or beef tea; subse- quently, he may eat part of the breast of a chicken or'game to dinner, till he is able to return to ordinary fare. The physician, in severe cases, ought to insist on his patient keeping notes of his diet, particu- larly during his recovery, which will enable him to compare his pre- sent state of health with the articles he had eaten the day before. The best diluents he can use are, an infusion of camomile flowers and lemon-peel, and wine and water; stimulants are to be commenced with great caution,and not until the pain in the epigastric region and heat of skin are subdued; perhaps the best stimulant is Cayenne pep- INDIGESTION. 237 per with food, which affects the whole bowels as well as the stomach, and tends to obviate constipation. Ginger tea will be found service- able, together with a glass or two of good sound wine once or twice a day. Wine sometimes, however, produces acidity, in which case a small quantity of brandy in water is found an agreeable substitute. Dyspepsia is one of those diseases too generally treated by the routine practitioner, from its name, without reference to the patholo- gical condition of the body on which the numerous symptoms de- pend. If such a person were asked, what he would prescribe for a person who had dyspepsia? he would quickly reply tonics! I have no objection to the medicines which are usually administered under the denomination of tonics, provided they are not given for the pur- pose of running up a bill, or prescribed at times when something better might be done for the patient. But 1 have some doubts re- specting the truth of the received notion of their action: I do not think it is by giving tone to the stomach. These remedies are bitter, and, I imagine, produce increased secretion of the fluids connected with the digestive process. On putting a little quassi or gentian into the mouth, immediately a flow of saliva takes place, which continues as long as the taste is perceptible, and even afterwards, when the person thinks of the bitter taste. May not a similar action in other organs follow the application of the same substance. If the liver be not doing its duty properly, calomel or the blue pill may be exhibited at bed-time, followed by a very small dose of salts in the morning; but it is a despicable practice to give blue pill in every disease connected with the digestive function. And it is much to be regretted, that the great name of Abernethy should ever have been associated with such insufferable quackery. The above treatment is to be persevered in for a long time, chang- ing the diet and the laxatives now and then, but continuing the counter- irritation and application of leeches alternately. After a time, cold bathing in the open sea may be cautiously tried; the shower bath, or sponging the body with vinegar and water, often produces the best effects. It would be needless to dwell here upon the treatment necessary in the third stage of indigestion, when some organic lesion is supposed to exist This must vary according to the organ diseased, as well as the nature and extent of the affection. The disease termed dyspeptic phthisis by Dr. Wilson Philip, is only met with, generally speaking, in cases of long standing. My 238 INDIGESTION. experience, however, leads me to state that bronchitis is the primary affection in such cases; the tubercles form subsequently. Flatulency and tympanitis.—These are symptoms of dyspep- sia, but require a few separate remarks along with heart-burn and water-brash. Some people suffer extremely from flatulency and acid eructations. Five or six instances have fallen within my observation, of individu- als who frequently passed enormous quantities of flatus upwards; and it is presumed these are cases to which Dr. Mason Good would ap- ply the term cholera flatulent a. In all such instances, the patient had previously eaten some crude vegetable substance: generally, the ordinary salad mixture, or radishes. The remedies which seemed to afford the greatest relief were aether, aromatic spirit of hartshorn, warm brandy and water, or brandy by itself, and essence of pep- permint. Tympanitis may be detected by percussing the abdomen; it is often a troublesome symptom, not only in this affection, but in fever; and the best remedy which can be used is turpentine. It is better to try it, in the first place, by injection, in the proportion of a table spoon- ful to eight or ten ounces of thin gruel, which the patient is to retain as long as possible. If this plan do not succeed, half an ounce is to be given by the mouth, with the same quantity of castor oil. Infants, during the first months, frequently suffer very much from flatus in the stomach and bowels, which will in general be found to depend, either on the pernicious and unnecessary custom of giving them castor oil and other medicines to open their bowels, or food they are unable to digest. In truth, the moment an infant is born, and often before it is dressed, castor oil is exhibited, which frequently produces griping; this is attributed to wind, and want of something to eat; therefore a quantity of gruel is given, which often increases the child's sufferings. Dalby's carminative is then given, which affords temporary relief. Few infants can be expected to thrive well under such management. The usual remedies for flatulence in infancy are, dill-water and oil of anniseed. Pyrosis, or water-brash.—In some long standing cases of indiges- tion, particularly in old people, in women more than men, and those who live principally upon farinaceous food, a considerable quantity of limpid fluid is discharged from the stomach by eructation. This is the affection which is called water-brash. It is a symptom of scir- rhous of the stomach also. GASTRODYNIA. 239 It attacks the patient generally in the morning and forenoon: at first considerable complaint is made of pain in the pit of the stomach, faintness, a sense of tightness, as if the stomach were closely drawn up to the back bone, and the uneasiness is increased upon moving into the erect posture; at last the limpid fluid is discharged in considerable quantity at different times, when the pain subsides; sometimes the fluid has an acid taste, but in general it is stated to be insipid. Occa- sionally the discharge takes place without being preceded by any severe symptom. Heartburn is, next to flatulency, one of the most frequent symp- toms in indigestion, and it is also one of the common attendants on pregnancy. When heartburn exists, the patient complains of a burn- ing pain in the pit of the stomach; every kind of food creates acidity; and hot acrid eructations take place, which seem to irritate the oeso- phagus. Some women suffer very much from this symptom during the whole course of pregnancy, but the moment delivery takes place, it generally vanishes like magic. Henry's calcined magnesia, and careful attention to the diet, often mitigate this symptom. The super-carbonate of soda and potass are frequently used, and sometimes with benefit; as also, charcoal and chalk mixture. The remedy which 1 have found most successful in producing temporary relief, is the common extract of liquorice. Cases are now and then met with, which resist all these remedies, together with leeches and opiates. The oxide of bismuth, sulphate of iron, and sulphate of zinc, have been highly extolled. I have exhibited them often in such instances, but without benefit. The points to be chiefly attended to, are the regimen and laxatives. GASTRODYNIA. The stomach is liable to a neuralgic affection, which is known by this name, as well as by the term cardialgia. Gastrodynia is closely connected with dyspepsia, often occurring as a symptom; but it may exist as the primary disease; sooner or later, however, the digestive powers suffer. Symptoms.—Sometimes the appetite remains good; but in general it is impaired. There is a gnawing pain in the stomach, extending very deep to the back, accompanied by anxiety, sense of constriction, tendency to eructate or to vomit, with occasional faintness, sometimes headache and constipation, and the patient is occasionally relieved by 240 GASTRODYNIA. eructation; a considerable quantity of limpid fluid is sometimes dis- charged; in fact, this affection is often complicated with pyrosis. After a severe attack, a patient sometimes escapes without another, for a week, month, or even a longer period. All the symptoms enumerated do not take place in every case; sometimes there being only pain and anxiety, with some nausea, which are increased after taking food. This affection is almost un- known before the age of puberty. Besides, depending on a diseased condition of the nerves of the stomach, it is probably occasioned by a diseased state of the pancreas, spleen, and liver. Sometimes it is pro- duced by scirrhosities of the stomach and duodenum, and it is also a very troublesome attendant on gout This disease has of late years excited a great deal of interest in France, as well as in this country; and although no additional light has been thrown upon the nature and seat of the disease, still very considerable practical advantages cannot fail to be derived from perusing the writings of M. Barras, and Dr. James Johnson. The chief causes of gastrodynia, generally speaking, are supposed to be, long-continued use of indigestible food, very hot or very cold drinks, dram-drinking, long fasting, worms. The chief articles which produce a paroxysm in an individual liable to the affection, are salads, and all other crude, uncooked vegetable substances, sweet-meats, new bread, cherries, nuts, olives, and above all perhaps, roasted chesnuts. The cure depends, therefore, upon avoiding such articles in future, to- gether with fat, oils, and butter. During an attack, a vomit will often suddenly check it, if exhibited within two or three hours after the offending matter has been eaten; hot flannels are to be applied to the epigastric region; gentle laxatives, and the warm bath, are to be employed, together with bitters, alkalies, magnesia; and in bad cases counter-irritation is to be persevered in for a considerable time. I have known one or two patients, who for many months at a time, could not put any kind of food into the sto- mach, without previously taking a small dose of the sedative solution of opium; and we are told by Roche and Sanson, that in the worst form of this disease, which had resistsd bleeding, bitters, and antispasmodics, Dr. Francois found lactucarium successful. It is a curious fact, that although sweet things generally aggravate the complaint, the extract of liquorice frequently alleviates the pain considerably. M. Barras insists much upon the necessity of making the patient take animal food, although it may for the time increase his sufferings. . CHAPTER IV. DISCHARGE OF BLOOD FROM THE STOMACH AND BOWELS. I. Haemorrhage from the Stomach.—This form, which is termed Haematemesis, is sometimes occasioned by diseases of the liver and spleen, and takes place also occasionally in fevers; but these are not under consideration at present. Haematemesis most frequently attacks women, particularly those who are unmarried, of a plethoric habit, and at times when there is an obstruction, or some other irregularity of the menstrual discharge? and who are constipated. Each attack is generally preceded by a rigor. Pure blood is seldom vomited, unless from external violence or the erosion of the coats of a blood vessel. This discharge rarely coagulates, and seems rather to be the product of passive haemorrhage, or exudation from the minute vessels of the mucous membrane. It is supposed to be a very easy matter to distinguish this affection from those haemorrhages which take place from the lungs. In haemateme- sis it is said the discharge is preceded by a sense of weight, pain in the region of the stomach, and that it is unaccompanied by cough, &c. But these distinctions will not answer in practice, and it may be of great consequence to a medical man, that he should not give an assur- ance of safety, in a case which may prove fatal in a few minutes, as the following instances will show.—A child was attended by Dr. Yates, when that excellent gentleman was a pupil at my Dispensary. It had been for some time complaining of cough and anomalous symp- toms, which were relieved from time to time, and it was able at last to go to school as usual. Still it occasionally discharged a little blood, and died suddenly, after vomiting a considerable quantity. On dis- section, the stomach was found filled with a coagulum, and there was also a considerable portion in the small intestines in a fluid state. It was evident that there had been active haemorrhage; but after the most minute investigation, no blood-vessel could be found from which Vol. I.—Jl 242 DISCHARGES OF BLOOD. it had issued. The relations began to complain of the time we had been over the body, and at length became very impatient, so much so, that we were obliged to give up further examination; but the whole of the contents of the thorax, including the oesophagus and great vessels, bavin"- been carefully dissected out, were surreptitiously con- veyed to my museum for minute inspection; and it was discovered that the blood found in the stomach and bowels, had proceeded from a ruptured artery in a cavern in the superior lobe of the left lung. A fistulous opening was found running upwards from this cavern, and communicated high up with the oesophagus; so that when ulceration produced a rupture of the vessel, the blood passed in this direction, and found its way into the stomach. The preparation is in the mu- seum, together with an accurate and beautiful drawing by my friend Dr. Alexander Thomson, an enthusiastic pathologist Another remarkable case occurred in the dispensary practice, in an old man. He had enjoyed remarkably good health until lately, when his appetite became impaired, and he complained of dyspeptic symp- toms, which gradually increased in severity, and he was at last re- luctantly obliged to seek for medical advice, at the age of 72, for the first time, I believe, in his life. He complained of so much uneasi- ness in the region of the stomach, that he was cupped several times, and counter-irritation was produced over the part affected, with con- siderable relief. One morning he discharged a little blood, between the act of coughing and vomiting, and he soon died after passing a considerable quantity. Upon dissection, it was a subject of general remark, that the external appearance of his body, as to shape and plumpness, was more like that of a man half his age. Every internal organ appeared sound; but on cutting through the stomach into the duodenum, the pylorus was found thickened and indurated, and an ulcer about the size of a horse-bean was discovered in the duodenum, on tfie surface of which the gaping mouth of a large artery was dis- covered, from which the haemorrhage had taken place. [Every part of the mucous membrane of the alimentary canal, is perhaps equally liable to passive haemorrhagic exudation. Occasion- ally the disease is so general as to give rise to a sanguineous cholera. In some instances it is confined to the bowels, the stomach not parti- cipating in it The most alarming variety of intestinal haemorrhage is called melama, and consists in copious evacuations of black blood, sometimes resembling ink mixed with sand; but in other instances possessing more obvious sanguineous characters. This modification of haemorrhage is attended by immediate exhaustion, which in a ma- jority of cases proves fatal.] DISCHARGES OF BLOOD. 213 Treatment.—As the disease generally attacks plethoric individ- uals, and is seldom accompanied by debility or oppression, practition- ers have no scruple in employing blood-letting during an attack, and it is frequently successful, by immediately checking the discharge. Quietness, cold acid drinks, and a course of laxative medicines, are also essentially necessary. If the haemorrhage recur after bleeding, or should it take place in a constitution already debilitated, the acetate of lead, either in solution or in the form of pill, in doses of two grains every second or third hour, will be found serviceable. [This medicine may be advantageously combined with opium and calomel. In melsena it is necessary, from the onset, to avoid every kind of active depletion, and support the patient by means of wine- whey, and farinaceous articles, followed, as soon as may be advisable, by mild bitter infusions. When the lower bowels are found to be distended from melaena, the blood is best brought away by simple injections of flax-seed mucilage, followed by an anodyne enema. I may add, that among a considerable number of patients affected with passive haemorrhage from the stomach and bowels, I never met with one that would bear venesection.] II. Haemorrhage from the bowels.—This was formerly known by the term Ilaemorrhoidal Flux, and it was believed by the ancients to be salutary; but now such a discharge is always regarded with anxiety, as it frequently tends to undermine the constitution, and like other long-continued haemorrhages, leads to affections of the brain,—a re- markable and fatal instance of which lately fell under my observation. When blood is discharged by stool, it will sometimes be found to proceed from an injury done to the verge of the anus by a hard and constipated stool, from a ruptured blood-vessel in the bowels, or from the diseased excrescences which are found at the termination of the rectum, known by the name of haemorrhoids, vulgarly called piles. These have been divided into two kinds, external and internal, which last are also called blind piles. They may be said to be painful ex- crescences on the verge of the anus, or in the rectum, usually attended with a discharge of mucus or of blood. The profession is not agreed as to their pathology; but after a care- ful examination of the opinions which have prevailed, and of the dis- eased parts themselves, I feel disposed to believe there are at least four distinct kinds of haemorrhoids. 1st, They are sometimes nothing more than a varicose state of the haemorrhoidal veins, with, perhaps, a slight thickening of the mucous membrane of the rectum itself. 2dly, They are formed by an efiusion of blood in the sub-mucous 244 DISCHARGES OF BLOOD. tissue, with a slight thickening of the membrane. 3dly, They are mere fugosities from the surface of the mucous membrane; and accord- ingly are found to vary very much in size, shape, and appearance. 4thly, A prolapsed state of the mucous membrane of the rectum, which subsequently becomes indurated, and in a manner strangulated, by the contraction of the sphincter. Symptoms.—Individuals who are thus afflicted, suffer only occa- sionally, and then it is said, in common language, they have " a fit of the piles." A sense of fullness is felt in the rectum, attended with an occasional stinging pain, which is sometimes very severe and darting, increased when passing a stool, during which a quantity of blood is discharged. A strong desire is experienced to sit and strain, which is termed tenesmus. After this has subsided, a sense of heat is felt for a few minutes. But when the piles are external they often swell enor- mously; are very tender, however small they may be, and sometimes ulcerated. In this case the discharge may be constant, taking place, however, in small quantity at a time; on other occasions there is copious haemorrhage, followed by relief from pain. When the in- flammation runs high, induration of greater or less extent is left, in consequence most probably, of effusion of lymph into the cellular mem- brane, to which may frequently be traced strictures in the rectum, and tubercular formations close to the verge of the anus. Causes.—The injury done to the parts by the frequent passage of indurated feces; use of aloetic purges; long-continued exercise in the erect posture; sitting on a cold or a damp seat; and every circum- stance which impedes the flow of blood through the veins of the abdo- men,—are causes of this complaint. The pressure of the gravid uterus, therefore, is sometimes a cause, as well as tumors affecting different parts of the uterine system, and diseases of the liver, &c. But it will be almost always observed, that individuals affected with piles, have been long and seriously afflicted with gastro-intestinal irritation.* Treatment.—The bowels must be kept constantly well regulated by the gentlest laxatives, carefully abstaining from the use of aloes in any shape. A large mucilaginous injection, exhibited immediately before going to stool, will be found highly serviceable, and the best way of preparing it is by making a decoction of linseed. Sulphur has been erroneously supposed to be a specific. Balsam of capavia was recommended and used by Dr. Cullen, by introducing it into the * The pernicious habit of taking a book or a newspaper to read in the water- closet, when at stool, is very frequently a cause of this unpleasant complaint. DISCHARGES OF BLOOD. 245 rectum; but in the ordinary cases of blind piles, gentle laxatives, occasional injections of decoction of linseed, together with rest in the horizontal posture, and a moderately antiphlogistic regimen, will suffice. When the piles are external, tender, and inflamed, the appli- cation of leeches or punctures made with a lancet, are also productive of great benefit, by diminishing the tension and pain. In severe cases the recumbent posture is actually necessary, and 1 have seen the in- flammation run so high, and attended with so much suffering, as to require general bleeding. Poultices and warm fomentations are very serviceable in alleviating the pain, and sometimes anodyne injections must be had recourse to; considerable relief is obtained, if the excres- cence can be pushed within the sphincter. An ointment, made by mixing equal parts of powder of galls and opium in hog's lard, and a weak solution of nitrate of silver, are frequently used with benefit. [A poultice of the fresh leaves of stramonium, pounded with crumbs of bread to the consistence of a poultice, affords great relief.] If a great deal of blood be lost, whether at once or at different periods, a careful examination should be made with the eye, as well as the finger, in order to ascertain the exact point from which the bleeding proceeds, and it is necessary sometimes to apply caustic, the ligature, and even the knife; but these are matters of surgery. 1 would only further beg to insist upon the necessity of attending more than is generally done in these cases to the constitution, and particu- larly to the general condition of the mucous membranes; and young practitioners should bear in mind, that neglected cases of piles often terminate in fistula. w CHAPTER V. COMMON COLIC; PAINTER'S COLIC; ILEUS, INTUSSUS- CEPTION; INTESTINAL CONCRETIONS; PROLAPSUS ANI; AND CONSTRICTION OF THE RECTUM. 1.—Common colic may be produced by indigestible food, constipa- tion, and a diseased condition of the biliary secretion. Symptoms.—Griping pains and flatulent distension of the bowels, with a sense of twisting in the region of the navel, are felt, sometimes with contraction of the abdominal muscles; and occasionally, though rarely, with some degree of nausea and vomiting, which takes place more frequently when the affection is produced by the biliary secre- tion, and in which case there is generally looseness of the bowels. Flatus is sometimes heard rumbling backwards and forwards in the bowels, which is more classically termed borborygmus. The pain comes on in paroxysms, during whi$h the patient thinks he experi- ences relief by pressure applied to the abdomen, which in general distinguishes the affection from others of an inflammatory nature. But it must be recollected that cases of colic, when neglected, often terminate in inflammation of the bowels. Treatment.—It is a most essential point to obtain free evacuations from the bowels speedily, particularly by means of an injection; cer- tainly the best is composed of tobacco, in the proportion of half a drachm infused for ten or fifteen minutes in eight or ten ounces of boiling water; to be strained, and exhibited when sufficiently cool. If the attack succeed immediately after a meal, an emetic may be given to dislodge the offending matter. A considerable quantity of oil of cloves should be administered along with castor oil, or any other pur- gative; or oil of turpentine may be used by injection. Warm fomen- tations to the abdomen, or the general warm bath, may be employed. Some cases of abdominal inflammation are attended by symptoms so slight as to resemble colic very closely, so much so, that in many instances it is diffic ult, and in some impossible, to determine this point of diagnosis. painter's COLIC. !M"i In such circumstances, it will be well for our patients if we do not at- tempt to refine too nicely; if in doubt whether the case be one of in- flammation or of colic, it is our duty to give the benefit of that doubt by using the lancet, particularly if the bowels are obstinate. [If the pain be severe, bleeding had better be resorted to without delay, inas- much as it not only relieves the pain sooner than any other remedy, but at the same time renders the bowels much more readily acted on by cathartics.] The advantage of opium is very doubtful till the bowels have been properly moved and the evacuation examined. [If, however, the violence of the pain demands it, it should be combined with free doses of calomel, viz: five grains of the latter with a grain or two of opium every hour or two until relief is obtained. I have also seen great benefit derived from heating brandy and cloves to- gether and applying the decoction, by means of flannel wrung out of it hot and dry, and applied frequently to the abdomen. A hot saline pediluvium contributes to the same end.] In a case of colic from vitiated bile, diluents, such as barley-water, are to be employed, together with a weak solution of salts, and after- wards opiates. If the bowels be open, and we are perfectly satisfied that there is no danger of inflammation, a stimulant, such as brandy, is often beneficial. Some women, at the menstrual period, have griping pains in the bowels, more particularly in the course of the colon, accompanied by considerable distension of the abdomen, attended or not by constipa- tion; frequently the pain extends from the caput caecum to the arch of the colon. The best remedy in such cases, is a turpentine or assa- foetida injection, combined with warm fomentations, proper regulation of the bowels and diet, and sometimes the warm hip-bath. PAINTER'S COLIC. This is also known by the names, collica pictonum, Devonshire colic; and in the West Indies it is commonly called dry belly-ache. This is the form of colic produced by the introduction of lead into the system, whether in food, by respiration, or cuticular absorption. It is a disease which was long known and described before its cause was dis- covered. The discovery was made in Germany about one hundred and thirty years ago, by detecting publicans putting a preparation of lead into their wines. It is said that the disease used to prevail in Devonshire, and other places where cider is manufactured, in couse- /> / 248 painter's COLIC. quence of putting lead into the casks, to render the cider sweeter. The disease also prevails in the neighbourhood of smelting furnaces and lead mines; indeed it is even said, in such situations, to affect the lower animals, such as poultry, pigs, &c. House-painters, plumbers, potters, glaziers, and all who are compelled by their occupation to handle lead much, are subject to this disease, particularly if they are not well guarded by personal cleanliness. Sir George Baker* was the first who drew the attention of the profession in this country to this interesting subject. It must be mentioned, however, that cases do occur displaying the same phenomena, course, and termina- tion, which have been produced by exposure to cold and damp, when there could not be the most remote suspicion of the action of lead upon the system. Symptoms.—The pain never leaves its principal seat about the um- bilicus and pit of the stomach; at first it is dull and remitting, but gradually increases to be very severe and constant. The pain, in some severe cases, strikes through the back, and patients have told me that it resembled a stab through the body; others have felt as if they were cut in two at the umbilicus. In other cases the pain extends to the arms and hands, down the back and pelvis, often affecting the lower extremities. The integuments of the abdomen feel retracted and hard, and I have seen the strongest men rolling and weeping like children. The whole surface sometimes suffers from pains, which the patients ascribe to rheumatism; there is also constipation, sometimes tenesmus, and occasionally sickness and vomiting. The. sickness and vomiting are most severe at the height of the paroxysm; acrid mucus is some- times vomited, or bile mixed with mucus, affording temporary relief. Hiccup sometimes supervenes, together with retraction of the testicles. It is matter which strikes every one with astonishment, that not- withstanding the,violence of the symptoms, and the excruciating suf- ferings of the patient, the pulse is rarely much affected till the disease goes on for some time; in the end, however, it becomes quick and small. It has been remarked by some, that the feet and toes are oc- casionally affected, as in gout. Spontaneous relief is said to follow a copious discharge of scybalous matter, like sheep's droppings, mixed with mucus and considerable quantities of blood. Occasionally, it is said, sweating produces a crisis. Sometimes the disease produces palsy of the superior extremities, and occasionally it terminates in death, which is preceded by a loss of * Vide papers in the 1st and 2d vol. of the Lend. Coll. of Physic. painter's colic. 219 sight and hearing, delirium, and convulsions. [The paralysis of the arms is in some cases confined to the extensor muscles, which at the same time shrink and almost disappear; while the flexors remain but little if at all impaired.] One attack leads to another; that is to say, a predisposition is left. Colica Pictonum is a most afflicting disease to treat; for, do what we will, the patient is seldom relieved under a week, even when well managed, and relapses often take place at times when he is apparently doing well. He may be pronounced to be in great danger, however, when there is delirium, violent spasms, and convulsions. Appearances on dissection.—The following is an abstract of the appearances found on dissection, in the bodies of a number of indivi- duals who died of this affection in the hospital of Beaujon, under the care of M. Renauldin. Redness, thickness, and ulceration of the mucous membrane of the aliamentary canal, and often enlargement of the mesenteric glands, corresponding to the inflamed or ulcerated portions of this membrane. The redness varied from that of bright rose even to violet and brown; it was disposed in points, in streaks, and in patches, and sometimes occupied an extent of several feet. The thickness was variable. The ulcerations were found almost always toward the termination of the small intestines, near the valve of the colon, which was sometimes destroyed; and in cases where diarrhoea prevailed, ulcerations were found in the colon; and sometimes they were observed in the stomach. They were occasionally deep, and numerous; sometimes the stomach and intestines were perforated.* Treatment.—The nature and seat of this disease are imperfectly known; but there can be no doubt, from the symptoms during life, and the appearances found on dissection, that it is probably seated, in the first instance, in the nervous system, and that we have to dread in- flammation of the mucous membrane of the stomach and bowels. I have often tried local bleeding by repeated cuppings and leechings on the abdomen and flanks; and lean speak confidently,from experience, of the good effect of this plan. I have always had an unaccountable dread of opening a vein in these cases, perhaps from prejudices of education; but since 1 have seen the above account of the appearances on dissection, my objections to it are so far removed, that I shall here- after try it, on proper occasions, cautiously. The remedies of the first importance, are calomel and opium, given • Vide Roche and Sanson, vol. i. |>. f>J8. These authors inform u- thai M, Renauldin had two hundred and seventy-five cases during the years 1*21 ±2-23. Vol. I.—32 250 painter's colic. in pills containing four or five grains of each, repeated at short inter- vals, so as to affect the system as speedily as possible. This remedial means has been strongly recommended by my friend Dr. Musgrave, of the island of Antigua. One of the most severe cases of colica pictonum that ever fell under my care, occurred since the publication of the first edition. The pa- tient was an apothecary's shop-man, aged 32, previous health good, and habits regular. The attack appeared to be owing to bathing the feet several times in a solution of acetate of lead, to suppress a fetid perspiration. In this case the paroxysms of pain were very distress- ing; the abdomen hard and distended; the features sharp and anxious, with hiccup and vomiting. The pulse did not exceed 80 till after venesection had been twice repeated, and large doses of calomel and opium administered, when it rose to 110. Venesection produced no relief; tobacco injections, fomentations, &c. were used in vain. The symptoms, however, became much mitigated after the third large dose of calomel and opium, conjoined with croton oil. He relapsed cer- tainly, but was convalescent on the third day, and recovered progres- sively. The bowels are extremely torpid in this disease, therefore common remedies must not be depended on; croton oil in doses of two, four, and six drops, must be given repeatedly at proper intervals, still con- tinuing the calomel and opium. Turpentine is to be exhibited, both by the mouth and by injections. Large injections are to be adminis- tered; sometimes stimulating, at others unstimulating. Hot fomenta- tions are to be applied; counter-irritation, when the disease is on the decline, which is to be for some time persevered in during the con- valesence. The nitrate of silver has been strongly recommended in three, five, and six grain doses, in pill three times a day.* Dr. Per- civalgave fifteen grains of the sulphate of alum every fourth, fifth, or sixth hour; and he assures us the third dose seldom failed to alleviate the pain.t It is proper to mention, that Dr. Reynolds has the credit of being the first who proved the powerful influence of opium over the morbid action produced in the system by lead. [The treatment which has proved most successful in Philadelphia, (where, from the extensive white-lead works, colica pictonum is a common disease) is the/ollowing, for which, however, I disclaim any * Uy Dr. Robert, 5th vol. Med. Trans. t Vide 2d vol. Ed. Med. Essays. ILELS. 2")1 originality, having adopted it for several years past, and applied it to a great number of cases both in public and private practice. Free bleeding from the arm, in the first stage of the malady, can seldom be dispensed with; after which the main object is to touch the gums with mercury, in order to relieve the bowels. Without this precaution the disease will often prove fatal; and even when the pa- tient survives, paralysis and a crippled constitution are almost sure to follow. To bring on the mercurial impression, and at the same time to relieve the pain, I give ten grains of calomel and two of opium, repeating this dose every hour or two, according to the violence of the attack. Simultaneously a blister should be applied over the abdo- men, which, as soon as drawn, is to be dressed with mercurial oint- ment. It may be even necessary to rub in the ointment on the thighs and arms. After the patient has taken four or five doses of the calo- mel and opium, his stomach, if retentive, should be plied with castor oil at such intervals as it will bear. If the stomach rejects all medi- cine, very large injections must be resorted to. These should consist of the usual drastic cathartics: but I have in several cases found co- pious injections of cold water to induce the peristaltic action, when every thing else has been unavailing. The bowels, however, will rarely yield in any considerable degree until the mercury takes effect, when purging becomes at once profuse, to the great relief of all the symptoms. I have never seen a death from colica pictonum when this plan of treatment has been followed from the beginning. M. Gendrin has published some observations on sulphuric acid as a prophylactic against lead colic. The acid is given in the form of lemonade, and is said to have proved eminently efficacious in the Parisian laboratories.] ILEUS. The attack comes on exactly like a common colic; afterwards vomiting takes place which subsequently becomes incessant; sometimes even feculent matter is discharged by the mouth, and the abdomen is much distended. The symptoms vary much in intensity. Sometimes the pain is severe, amounting to tormina; at others it is slight. In some cases the febrile symptoms run high, in others there is no fever. In this, and even in common colic, the abdomen should be minutely examined with the hand, to ascertain whether or not a hernia exists; 252 ILEUS. for I have seen two or three instances where much valuable time was lost, in consequence of mistaking a case of hernia for colic. Appearances on dissection, and pathological remarks.—Consi- derable dilatation of one part of the intestine is generally seen, while the continuous part is contracted; the parts above the contracted por- tion, are frequently distended with fluid and flatus. Sometimes the intestine is of a livid colour, inflamed and even mortified. At other times there are marks of peritoneal inflammation; and on some occa- sions, gangrene, without peritonitis. In treating of the nature and seat of this disease in the first edition, opinions similar to those of Dr. Abercrombie were advanced, viz. that the disease probably consists of " a paralysis of the intestinal tube, which leads to great dilatation; while the continuous portion of the bowel is contracted, which produces a temporary obstruction." " But, (it was added,) there is much ambiguity on this subject." Since that period I have thought frequently on the subject, and from an interest- ing conversation with Dr. William Stokes of Dublin, one of the most ardent and accurate pathologists in this country, 1 have become con- vinced that Dr. Abercrombie's views are erroneous. In fatal cases of ileus, the bowel has been generally found in two opposite conditions,—one part contracted like a cord, and another part above much dilated. The point to be determined is, which of these is the primary seat of affection. Dr. Abercrombie thinks it is the dilated portion, and that " the doctrine of spasm, as applied to this subject, must be admitted to be entirely gratuitous; and we must proceed ujjon facts, not upon hypothesis, if we would endea- vour to throw any light upon this important pathological ques- tion."* In the last sentiment 1 most cordially agree; and as I think the author has substituted hypothesis for facts, I shall shortly state several reasons for dissent. 1st, Dr. A. avers, that " the collapsed stale of the intestines, in ivhich it assumes the form of a cord, appears to be the natural state of healthy intestines." « That in a case of ileus, the dis- tended part is the real seat of the disease; and that the contracted part is not contracted by spasm, but is merely collapsed because it is empty, its muscular action being unimpaired;" p. 136. We submit, that the cord-like contraction is not the natural state of intestine. If it were the natural condition of parts, it would be always seen on dissection, when the bowels are unaffected by disease; whereas * Researches on the bowels, p. 134. ILEUS. 253 it is avowedly rare, and according to our observations, is only seen when^the intestinal tube is in a morbid state. This appears to be satis- factorily proved by Andral, Billard, and others. We have examined the bowels of animals, opened during life, and on no occasion found the tube in the state which is asserted by Dr. Abercrombie to be natural. 2dly, It appears to us that Dr. Abercrombie does not connect ileus with any known pathological state. He considers ileus to be a great and uniform distension of a part of the intestine, with loss of power of its muscular fibres. In short, he supposes the distended intestine to be in the state of paralysis, and that this is the primary disease. He states, also, that the " usual progress of the disease is into inflamma- tion and its consequences;" p. 138. Dr. Abercrombie cautiously avoids the term " paralysis;" but it must be admitted, that loss of muscular power proceeds either from paralysis, or inflammation in the part. If paralysis, it is the opposite of the state of irritation, for innervation is abstracted, not added. If inflammation, then Dr. Abercrombie is wrong; but in neither case can he be correct. It will be observed, also, that he does not denominate the cord-like state of the intestine, "contracted," which he ought, but " collapsed," which term he ought not to have employed, because it conveys any thing but a correct notion of the actual state of parts. 3dly, When we speak of a muscular organ such as the intestine, we must admit spasm to be possible, nay, probable; and we cannot therefore admit the doctrine of spasm, as applied to this subject, to be " entirely gratuitous." No one denies the muscularity of the intestines, and that they are capable of contraction, which implies an increase of innervation. If Dr. Abercrombie's idea were correct, the bladder should never fill, nor the heart, nor the feces pass through the intestine, unless muscular fibre could be stimulated to dilate. But it will be proper to allow Dr. Abercrombie to speak for himself. <• If we suppose then that a considerable tract of the canal is in a collapsed state, and that a mass of alimentary matter is propelled into it by the contraction of the parts above, the series of actions which will take place, will probably be the following: When a portion which we shall call No. 1, is propelling its contents into a portion of No. 2, the force exerted must be such, as both to propel these contents, and also to overcome the tonic contraction of No. 2. The portion No. 2, then contracts in its turn, and propels the matter into No. 3; this into No. 4, and so on," p. 136. It will be readily seen, on looking at the parts, that the empty in- 254 ILEUS. testine is not in a state of "tonic contraction," as Dr. A. asserts, and that it offers no resistance to the alimentary mass, which is propelled onward by the contraction of the superior portion of intestine. 4thly, If the dilated intestine usually passes into inflammation and gangrene, and its seat be in the muscular coat, its first stage must be one of irritation. The effect of irritation on muscular fibre is, to sud- denly and powerfully contract it. The parts may become dilated afterwards, but the first effect will be contraction—and the contracted, of course, the diseased portion. It follows then, as a necessary conse- quence, that if it be spasm, the contracted is the diseased portion; or if, according to Dr. Abercrombie, it be disease of the muscular fibre, still in the first instance the same will occur. Ileus, according to Dr. Abercrombie, is either a paralysis, or an irritation of the muscular fibres of the intestine, usually terminating in inflammation and gangrene. Could any two things be more oppo- site? If it be a paralysis, it is either general or local. It is not general, because all the symptoms are those of violently increased action, colic, vomiting, spasms of the abdominal muscles. And paroxysms of tormina! Tormina and loss of power together? If it be local, it is at all events accompanied by increased muscular action—spasm. If the primary diseased action be connected with irritation, as we imagine, the first effect will be to contract the parts. Lastly, It may be asked, does the treatment coincide with the doc- trine of paralysis, or that of irritation and spasm? After describing the treatment, 1 shall return to consider this important question. Treatment.—The chief attention must be directed to prevent and subdue inflammation, and to employ every means to move the bowels. For this purpose the milder laxatives, frequently repeated, assisted by tobacco injections, are to be had recourse to. If these fail, then we may entertain the question of bleeding, particularly if the case be not far advanced, and if there be pain on pressure. Leeches may be applied; but still we mustnot lose a moment in endeavouring to procure a stool. Although we may mitigate the symptoms by bleeding and leeching, yet we may rest assured that relapse will take place in the course of an hour or two, unless the bowels are opened. Dashing cold water upon the belly has sometimes succeeded. When the gut is supposed to be obstructed, mercury in its pure metallic state has been recommend- ed to be poured into the stomach in considerable quantity, in order to force a passage. Once 1 was present at a dissection, when the ob- struction existed at about six inches from the termination of the rec- tum; and since them I have met with two cases of ileus, which were INTUS-SUSCEPT10.N. 255 produced by constriction of long standing of the rectum; therefore, I think, in all severe cases of this sort, that a long oesophagus tube should be introduced into the rectum, and if possible, pushed forward into the sigmoid flexure of the colon. This is one of those diseases in which we frequently succeed in pro- curing passage from the bowels after bleeding, which had previously resisted the strongest purgatives; it is also one in which large opiates may be advantageously combined with laxatives. Opium generally acts by confining the bowels; but in the case now before us, it seems to increase rather than diminish the laxative effect of medicines. Du- ring recovery it may be adviseable to apply counter-irritation. It has been already asked, if the most improved remedial means coincide with Dr. Abercrombie's hypothesis? Bleeding, tobacco ene- mata, full doses of opium, and counter-irritants, to cure a disease which is a simple loss of the muscular power of a portion of the intestinal canal? The circumstances cannot be reconciled upon principles of pa- thology; neither will they bear the test of common sense. Had it not been for the deservedly high reputation of the author, I would not have condescended to refute such an hypothesis. Much real injury is done to the advancement of medical science, by the construction of such distorted theories; and I cannot resist quoting a passage from the preface of Dr. Abercrombie's work on the bowels, which bears on the present question. Speaking of the circumstances which have retarded the progress of medicine, he says there are two errors com- mitted—the one is the " construction of hypothetical theories, or the assumption of principles which are altogether gratuitous and i?n- aginary; the other is the deduction of general principles or conclu- sions from a limited number of facts." P. ti. INTUS-SUSCEPTION. Intus-susception, generally speaking, is a disease of infancy. There are the same symptoms as described in ileus, only that in many cases there is violent straining; the patient passing more or less bloody mucus with each effort, in some instances exactly resembling red currant jelly. This, like all other affections, varies very much in the symptoms as to violence; this was well proved in two fatal cases occurring in the same family, which fell under my immediate notice. They were both male infants at the breast; the disease ran its course 256 INTUS-SUSCEPTION. in three days; but the symptoms were very violent in one case, and very slight in the other. In both, a tumour was felt in the left iliac region, at the termination of thirty-six hours, which gradually in- creased in size, till it became as large as an orange. Both children strained much at stool, and passed mucus tinged with blood. The disease has been known to terminate fatally in thirty hours. Appearances on dissection.—We often find partial invaginations of the small intestines. I scarcely ever open a child without finding them; but they are not to be regarded as intus-susceptions, unless the coats are thickened, with marks of inflammation. At least so I thought when the first edition was written. Since then, however, I have be- come doubtful on this point, having discovered ulcerations in the in- testines at each intusrsuscepted part, in every case which I have had an opportunity of examining. In the dissection of patients who die of intus-susception, it is the caput caecum, and a portion of the ileum. which are commonly forced up by the ascending colon across the transverse colon, and sometimes down to the sigmoid flexure. In one of the cases to which I have alluded, the caput caecum was found in the rectum, very near to the extremity of that gut; and it appears to me that this never could have taken place unless there had been some original malformation. Upon first opening the abdomen, in both cases mentioned above, the intestines looked displaced and twisted, and the caput cajcum was missed from its usual position in the right iliac region. On slitting open the intestine at the point of obstruction, we find two mucous surfaces highly inflamed, dark-coloured and thickened, and covered with a considerable quantity of effusion of a red colour, inter- mixed with whitish matter like coagulable lymph. On laying open the intestine which is invaginated, we then expose to view two serous surfaces, which are also found in a state of inflammation, with exuda- tion and adhesion. Treatment.—The same plan is to be had recourse to as in ileus, only this is altogether a more hopeless case; we are to be more guard- ed in using strong purgatives, for fear of increasing the torments of the poor little sufferers. It is said that a natural cure sometimes lakes place by a spontaneous separation of the inlus-suscepted portion of gut; and in every extensive collection, a preparation or two of this kind is exhibited. INTESTINAL CONCRETIONS. 257 INTESTINAL CONCRETIONS. Some remarkable cases of this kind are on record; but man is not nearly so liable to the complaint as some of the lower animals. A case is published in the eighth volume of the Edinburgh Medical Com- munications, by Dr. Fitzgerald. The patient, a lady, suffered extreme pain in the hypogastric region, the back, and os sacrum, for eighteen months; during the last three of which she could not leave her bed, except to be put into the hot bath, which afforded only temporary relief. One day, after receiving an injection, a large, hard, calcareous ball, of an oval figure, was discharged. It exceeded in size an or- dinary orange, and so solid, that it required the stroke of a hammer to break it. It weighed eight ounces and three drachms. Sometimes there arc several of these concretions; in that case they may be heard rattling upon percussing the abdomen. Many curious instances of this affection are related in the Philosophical Transactions. The late Dr. Marcet wrote an essay on the chemical history and medical treatment of calculous disorders, wherein notice is also taken of several interesting cases, to which I must refer the reader, as well as to the first volume of Good's Study of Medicine. It is alleged that the inordinate use of chalk and of magnesia in dyspeptic and calculous complaints, leads to the formation of these substances. MasOn Good mentions a case of a lady whom he had once attended; she "laboured under a most painful constipation, till a large mass of what may be called intestinal mortar, was removed by a scoop from the rectum:" p. 297, vol. 1st. Treatment.—If the nature of the disease be discovered, large mu- cilaginous injections ought to be frequently administered, alternately with those of an anodyne nature, to allay irritation. Blisters and leeches may sometimes be necessary, to allay internal pain, and mode- rate any inflammation that may arise. If such substances can be felt through the parieties of the abdomen, as is alleged, and made to rattle together, it may perhaps be possible to push them on daily in the course of the bowel towards the rectum. In females, I can conceive it to be very easy to break them down when they arrive in the rectum; and considerable assistance will be afforded by introducing one or two lingers into the vagina. The warm bath is not to be neglected. D Vol. I.—33 258 CONSTRICTION IN THE RECTUM. PROLAPSUS ANI. By this term is understood the protrusion of a portion of the mucous membrane of the rectum, the sphincter contracting forcibly, and pro- ducing a temporary stricture. Prolapsus ani depends either upon a want of power on the part of the sphincter ani, or some violent irrita- tion in the rectum, producing great straining, which, in medical lan- guage, is termed tenesmus, during which the mucous membrane is protruded. It is now much more rare than formerly, owing to the greater attention which is paid to the bowels of children, who are generally the subjects of this complaint. Formerly a pernicious custom prevailed of endeavouring to produce a stool, by making children sit upon a pot containing a little boiling water, instead of giving them physic. Symptoms.—The protrusion takes place when the child is bearing down at stool, or making water; it begins to cry most violently, from the pain in the part affected. On making an examination, the mucous membrane is found of a dark red colour; the protruded portion is of various sizes, sometimes as large as a small orange. Formerly a piece of scarlet cloth was applied to the part by the women, under the idea that it would be thus reduced; but now almost every nurse knows how is should oe reduced. The child being placed on the back, gentle pressure is to be applied to the protruded portion of gut, by the thumbs of the operator, which have previously been dipped in oil. [If the protrusion has continued so long as to cause violent inflammation, rendering the return of the intestine impossible, leeches may be ap- plied with great advantage. The case of an adult recently came under my care in which the gut remained exposed for nearly 48 hours, and only become manageable after free leeching.] People advanced in age are sometimes affected with prolapsus ani; it frequently depends upon diseases of the urinary organs, as well as of the bowels. The parts are occasionally so much relaxed as to re- quire a surgical operation. CONSTRICTION IN THE RECTUM. Little need be said respecting constriction in the rectum in a work on the practice of physic; indeed, the subject is introduced only for CONSTRK TION IN THE RECTUM. 259 the purpose of drawing the attention of physicians to the subject. I have seen several cases within these few years, in which many danger- ous attacks of constipation might have been avoided, had the disease in the rectum been early discovered. This affection may be suspected in every case of habitual constipation, particularly in those instances where the patients have to strain long at stool before the least passage can be procured. Laxative medicines afford only temporary relief, and when too powerful, 1 have seen symptoms of ileus induced. The only remedy is to be found in the frequent introduction of the bougie. I have lately been consulted in two instances where symptoms of ileus were occasioned by this affection; both patients were permanently cured by dilating the stricture. CHAPTER VI. INTESTINAL WORMS. Thehe arc principally three kinds of worms which infest the intes- tinal tube, the lumbricus, tenia, and Ascaris.* 1st, Lumbricus.—It resembles the common earth-worm, and may exist in considerable numbers; instances are on record of upwards of fifty having been voided. Lumbrici lodge in the small intestines, and occasionally in the stomach, and are therefore frequently vomited. They often excite little uneasiness, but in some cases they create con- siderable constitutional suffering. 2c?, Tenia, or tape worm.—Of this genus, there are two species, the tenia solium, and tenia vulgaris. The first, as its name imports, is solitary; the second may exist in families. They generally take up their quarters in the higher parts of the intestines; for the pur- pose, as is supposed, of feeding on the chyle. Tape worms appear to be composed of a great number of pieces or animals joined together by articulations. In the tenia solium these articulations are long and narrow; while in the other kind they are short and broad. The soli- tary tape worm has been known to measure between thirty and forty feet; and one extraordinary worm is mentioned by Dr. Sibbargarrde of Copenhagen, which measured thirty-eight yards. The tenia vul- garis measures generally from three to twelve feet. 3d, Ascarides generally lodge in the rectum, enveloped in mucus; they are the smallest, being only like threads, from an eighth to a quarter and half an inch in length. Worms chiefly exist in children and sickly adults, and generally depend on some diseased condition of the secretions in the alimentary canal: I believe the inhabitants of Great Britain suffer less from them * There is another kind of worm, which is rare—the trichuris; but of which I shall not treat, being more an object for the natural historian. Another species, never before described, lias been lately discovered in my collection, by Captain Brown, an ingenious naturalist. INTESTINAL WORMS. 261 than any other nation. Mr. Marshall, deputy inspector general of hospitals, informs me that Europeans are very liable to lumbrici in India, and perhaps Africans are more so. Few post mortem exami- nations are made without discovering them. One negro passed forty lumbrici in one day; in seven days he passed altogether two hundred. Worms frequently produce emaciation, swelled and tense abdomen, gnawing and slight burning pain in the stomach and bowels; irregular appetite; pale, sickly countenances; foul tongue; fetid breath; irri- tation and inflammation of the nostrils, occasioning great itching and desire to pick the nose; occasional feverishness, particularly at night, producing restlessness and want of sleep. But none of these symp- toms, nor all of them conjoined, point out the positive existence of worms, because they may be produced by any irritation or subacute inflammation in the mucous membrane; and it is too much the custom for medical men to conclude that a child has worms, if it is dull, looks pale, and is constantly observed with its fingers in the nose. Besides these symptoms, worms occasionally produce violent colicky affec- tions, with vomiting and purging, sometimes of blood; and, 1 believe, ulceration of the bowels, and even peritonitis, may be excited by this irritation. More rarely, cerebral symptoms, and even epileptic con- vulsions, take place. Children who are troubled with worms, often awake suddenly, screaming, and frequently are observed to grind their teeth. Treatment.—The first thing to be done is to endeavour to repair the digestive function, and at the same time, we must institute an ex- terminating war against such filthy intruders, by means of a class of medicines called anthelmintics. It is curious, however, that the remedy which appears to succeed in one or two cases, will disappoint our ex- pectations in a number of others. Anthelmintics naturally divide themselves into two classes, one which operates mechanically, namely, ordinary purgatives, common oils, sulphur, sea-salt, tin-filings, cow- hage; another, which has a peculiar poisonous effect on the animal, as oil of turpentine, hellebore, male fern, tobacco, rue, calomel, and other mercurial preparations. Of all these, oil of turpentine, calomel, jalap, and the cowhage, have been most successful.* It deserves to be mentioned, that turpentine, in duses of from one to two ounces, is the only remedy which has hitherto been found generally successful in destroying the tenia. It has been mentioned to me, however, that a decoction of the root of the pomegranate tree, is fully as successful ' Sec Appendix, Prescriptions 51 to 57. 2G2 INTESTINAL WORMS. in expelling tenia as oil of turpentine. When turpentine is given by the mouth, care should be taken to have the bowels previously well opened, so that it may not be detained in the intestines. The condi- tion of the stools must be watched, which, together with other symp- toms, treated of under the head, " Usual Complaints of Children," will generally announce whether there be any considerable irritation or inflammation in the mucous membrane. Should such symptoms exist, the application of leeches, or of a counter-irritant, may be ne- cessary. CHAPTER VII. INFLAMMATORY AFFECTIONS OF THE ORGANS CON- TAINED WITHIN THE CAVITY OF THE ABDOMEN. GENERAL REMARKS. Inflammations of theviscera havebeen distinguished, since the time of Boerhaave, by anatomical terms, derived from the name of the tissue or organ affected, with the addition of the Greek term, His; as Gas- tritis, Enteritis, Peritonitis, Arachnitis, &c. It would be an error to suppose that in inflammatory disorders, the constitution is always disturbed in proportion to the importance of the part affected, and the nature and extent of the diseased action. If the organ be a vital one, the disease is certainly attended with more danger, than if the inflammation attacked an ordinary muscle, or the cellular substance to the same extent; and the disease is much more rapid in its progress; but there is often more pain and a higher fever when the inflammation is situated in the latter tissues, than in the brain, lungs, Sac. The constitutional suffering which happens when vital organs are affected with inflammation, is attempted to be explained by the term sympathy; it is said in medical language, " the organs sympathize with each other." Thus, Dr. Good observes at page 384, vol. II. " When inflammation is seated in the heart, its action becomes ex- tremely agitated and irregular. When in the lungs, the heart, possi- bly from sympathy, does not seem to allow a free diastole." It would afford me much real satisfaction, if the word sympathy were always employed in medical writings in a strict pathological sense, as I conceive it would be a great step gained in the practice of medicine. It is one of those vague terms too often employed to ex- press a cases of fever, and in the last stage of phthisis, in which the mucous membrane is removed over a great extent of surface, leaving the parts of a dark colour; the other is ob- served in the intestine, and particularly about the caecum and ascend- ing colon, in which the mucous membrane is lying loose, and in shreds of a very dark colour, and having the most offensive gan- grenous odour. Inflammation of the mucous membrane, more particularly of the colon and rectum, terminates in a general thickening of the membrane and the submucous tissue; and occasionally also the muscular coat is involved. The mucous surface is soft and spongy, sometimes abraded and very much discoloured; in some places of a bright red; in others of a dark mulberry colour; no distinct vessels can be seen, and the discoloration seems to be partly owing to infiltration of blood. This appearance is very apt to be confounded with mortification, and is principally observed in the most acute form of tropical dysentery} but I have had many opportunities of seeing it in this country, in cases which ran their course in from eight to fourteen days; and in some of these instances the intestine is more than the eighth of an inch in thickness. In some cases I have seen the mucous membrane of the colon and rectum, together with the muscular coat and submucous tissue, simply in a state of hypertrophy, to a great extent, which appeared to me to be the result of former inflammatory action; many of the subjects had been in warm countries, and had suffered from dysentery. It is well known that ulcerations, which are attended with con- siderable loss of substance, undergo the healing process; and for some time afterwards the parts so restored may be distinguished by an ap- pearance of cicatrization, which pathologists are well acquainted with, and which is best observed in old cases of dysentery. Sometimes we see tubercles in the mucous membrane itself, with more or less extensive ulceration; or the tubercles are found in the sub-mucous tissue, with ulcerations on the mucous surface, in various stages and extending from the tubercular elevations. These appear- ances are also principally seen in the colon in cases of phthisis. There are no doubt, many other appearances which are produced bv inflammatory action in the mucous membrane; but a minute de- scription of all would require a separate treatise, and is not consistent with the plan of this work. Vol. 1.—37 290 INFLAMMATION OF THE Competent judges may deem the above description very imperfect. I can only say it is drawn from nature, and it will afford me much pleasure to demonstrate its general correctness, by showing prepara- tions and drawings in my collection from which it is taken. INFLAMMATION OF THE MUCOUS MEMBRANE OF THF STOMACH. [Gastritis.] It is difficult to determine the meaning of most writers when they speak of gastritis. Some use this term to indicate inflammation of the peritoneal coat of the stomach, which is a rare disease: others, the mucous. Inflammation of the peritoneal coat of the stomach has been already treated of in this work under the term peritonitis. By gastritis, I mean to express an inflammation of the mucous membrane of the stomach, frequently involving the sub-mucous tissue, and occasionally the muscular coat. A great deal of obscurity also prevails in different works, from the use of the terms phlegmonous and erysipelatous, adhesive and erythematic, which I shall therefore be careful to avoid. Inflammation of the mucous membrane of the stomach exists in various degrees of intensity, from the most acute to the slighest sub-acute form; and it may also be chronic. Acute inflammation of the mucous membrane of the stomach is a rare disease; it generally exists in a sub-acute, and a chronic form. Syinptoms of gastritis.—There is a burning pain in the region of the stomach, increased on pressure; a constant desire for cold drinks, which are immediately vomited; nausea, and an inclination to retch, are incessant; the heat over the surface of the epigastric region is considerable, while the extremities are perhaps cold. At the same time the patient frequently complains of sore throat; and upon ex- amination, the fauces will be found inflamed. Hiccup is a trouble- some symptom. The state of the tongue cannot altogether be depended upon; in general, however, it is very red at the tip, and round the edges; loaded, and occasionally very rough in the centre, and towards the root; sometimes, in long-standing chronic inflammation, it is red, glazed, and smooth; although I feel persuaded that this last condition of the tongue takes place more generally when the intestines are in- flamed and ulcerated, than the stomach. The breathing is anxious MUCOUS MEMBRANE OF THE STOMACH. 201 and quick, and the patient restless; the pulse is small, and the pros- tration of strength soon becomes very great; the countenance is ex- pressive of great anxiety, and the individual makes great complaint. Towards the termination of the disease, the features shrink, and the patient lies upon his back. The matter vomited in the early stages consists of the fluids taken into the stomach, occasionally mixed with bile and some mucus; but at last the black vomit takes place. The bowels are generally constipated. There is scarcely any acute disease which so quickly exhausts the powers of life; and hence it is said, that the symptomatic fever is of a typhoid type. It happens occasionally, however, that the symptoms are exceedingly mild, even when the disease has been produced by mineral poisons; and appearances denoting great danger do not come on till within a few hours of the fatal termination. This was particu- ' larly well marked in a soldier of the 17th foot, who swallowed two drachms of the muriate of mercury, and who died unexpectedly eight or ten days afterwards on the close stool, having been able to get out of bed, and walk to it unsupported. It has been already stated, that the acute form of this disease is a very rare occurrence, and that it more frequently exists in a sub-acute and chronic form; and we see these most frequently in fevers, in dys- pepsia, and in the last stage of phthisis. Causes.—This disease is produced by any of the common causes which occasion inflammation; by wounds and contusions, as well as by poisons and other acrid substances taken into the stomach, also too great indulgence in the use of ardent spirits; it sometimes follows in the train of other diseases, as cholera morbus, &c. Appearances on dissection.—On opening the stomach, a consider- able quantity of thick, tenacious mucus will be observed; and the mucous membrane itself will be found in one or other of the conditions already noticed in the general description. It may be mentioned, that the appearances produced by poisons so closely resemble the lesions occasioned by ordinary inflammation, that no distinction can be made; and the nature of the case must rest upon the fact of poison being found, and its powers ascertained. Treatment.—Bleeding copiously and frequently must be had re- course to, and at short intervals; there is no disease which requires a more decided use of the lancet. The application of leeches in con- siderable numbers may also be found necessary, either after the inflam- mation has been somewhat subdued by the lancet, or when the physi- cian is afraid that it is too late for general bleeding. Blisters are, of 292 INFLAMMATION OF THE course, to be employed in severe cases. Laxative medicines are also necessary; but it is needless to administer them till the diseased action is considerably subdued, as they will increase the already too irritable state of the s'tomach; therefore, in the first instance, we are to endeavour to open the bowels by means of injections. Opiates are also useful; but it is necessary to caution young practitioners against the routine practice which is too generally followed, of giving opium whenever there is irritability of the stomach. When opium is given, it is often advantageous to exhibitit in the form of pill com- bined with calomel. The warm bath, and hot fomentations to the part affected, are means which must not be neglected; and it is necessary to restore and support the natural heat of the extremities. During convalescence, the diet must be carefully attended to, and 1 should merely consist, for the first day or two, of arrow-root or fine oatmeal gruel. INFLAMMATION OF THE MUCOUS MEMBRANE OF THE BOWELS. [Enteritis.] Inflammation of the mucous membrane of the bowels varies per- haps more, in its external signs, than that of any other structure in the body, and for the most part its attack is most insidious. The dis- ease is most frequently met with in a sub-acute and chronic form; even when acute, the symptoms are sometimes exceedingly mild; and this takes place occasionally in cases where we subsequently find, on dissection, not only the most extensive inflammations, but ulceration, which will be more fully shown when treating of dysentery. Symptoms.—The combination of symptoms denominated fever, take place with more or less intensity; in fact, as already shown, in- flammation of this tissue is the cause of many of the fevers which prevail in all climates. Pain is often very slightly felt in comparison with that which generally attends peritonitis; when the small intestines are affected, the pain is experienced more about the umbilicus than in any other region; cold drinks aggravate it, as well as any indigestible substance taken into the stomach. The pulse is found in very different states, even during the same day; it is frequently quick, but not in ge- neral so hard as in peritonitis. The skin is generally hot and parched during the day and night, but towards morning some degree of mois- ture takes place, and it is then only the patient enjoys comfortable sleep. Thirst is often very urgent. MUCOUS MEMBRANE OF THE BOWELS. 293 Tympanitic distension often causes considerable suffering to the pa- tient, and aggravates the constitutional symptoms. The tongue is not altogether a sure index of the state of the mucous membrane, as I have seen it perfectly clean and natural in colour, or foul without red- ness, when dissection revealed most extensive inflammation. But in general the tongue will be found to be more or less red at the tip, and round the edges, however much it may be loaded in the centre; sometimes it is altogether red, and looks raw, and per- fectly smooth like varnished leather; and when it is unusually red, 1 look upon it as a certain indication of very considerable irritation, or of some degree of inflammation or ulceration of the mucous mem- brane of the bowels. When the superior parts of the tube are dis- eased, there is more or less nausea and tendency to vomit; when the inferior parts are implicated, we find pain in the iliac regions, and in the course of the colon, with more or less diarrhoea, and consider- able discharges of flatus; and when the colon is severely affected, there is that twisting pain in the bowels, which in medical language is denominated "tormina;" it comes on .in paroxysms, with intervals of perfect ease. The patient complains of it every hour, or half hour, and even at shorter intervals, and it is always followed by an irresisti- ble desire to go to stool. When the rectum is involved, there is con- siderable straining, and the patient can scarcely be induced to leave the close stool, and yet he passes nothing but a little mucus mixed with blood, or a small quantity of scybalous matter, with some flatus. Every experienced medical man, upon reading these passages, will perceive that I have been describing the symptoms of diarrhroper functions of the liver, after diseased action has been reduced, than in reducing that action itself. The warm bath is to be frequently employed. The diet should be of the blandest description, and the patient must avoid fatiguing exercise, particularly on horseback, for a considerable time after his convalescence. When the disease is severe in India, removal to a colder climate is considered very essential, and remarkable recoveries have taken place during the homeward-bound voyage. It must not be supposed, from my statement regarding the limited use of mercury, that I have joined the standard of those who perti- naciously resist the employment of mercury in all diseases, and who insist that every little eruption, or accidental disease of a bone, or chronic ulceration of the throat, is produced by the action of mercury, although the individual may not have taken a grain of it for twenty or thirty years. It is said that mineral waters, as those of Cheltenham and Harrow- gate, are found exceedingly useful in diseases of the liver, as also the nitro-muriatic acid bath; and I think benefit has been derived from the use of iodine; but it becomes me to speak doubtfully respecting these remedies. Chronic hepatitis, and other diseased states of the liver, are to be treated pretty nearly upon the same principle; except drawing blood from a vein, which is rarely called for; whereas the action of mercury is likely to be more beneficial than in the acute forms of the disease. [The nitric and nitro-muriatic acids are im- portant remedies in chronic liver disease: sometimes they happily supersede mercurials, and in other cases may be alternated with them.] I have a few words to say respecting scirrhus of the liver and tu- bercular formation. The true scirrhus of this organ is, 1 imagine, as rare as mortification, and as a congested appearance is often mistaken for mortification; so is tubercular formation for scirrhus. A diseased state of liver, corresponding to scirrhus in other organs, is, however, occasionally seen, and is to be distinguished by its indurated condition, and its white bands. Another appearance similar in every respect to medullary sarcoma is occasionally observed, of which I have seen two or three instances, and possess a drawing taken from one case.— DISEASES OF THE LIVER AND SPLEEN. 351 Sometimes, tubercular formation may be traced, extending fYom the •peritoneum into the substance of the liver; the peritoneum having a thickened, opaque, and sometimes puckered appearance, occasionally contracted inwards, so as to give a resemblance of loss of substance from the discharge of an abscess. On some occasions, the tubercular masses project frdfci the surface of the liver, producing a lobulated appearance. Sometimes, however, the peritoneum looks perfectly healthy, although there may be considerable enlargement of the organ itself; and when cut into, large tubercular masses are discovered, sometimes near the surface, at others deep seated, which look yellow, and resemble the general tubercular infiltration which takes place in the lungs. The liver is sometimes found studded with yellow bodies of different sizes and shapes. The organ is of a reddish tint, and these bodies look like yellow wax sunk into the texture. They are not like tubercles. Andral considers that they are merely the white substance in a state of hypertrophy. Laennec believed them to be an acciden- tal tissue found in the liver, and termed the disease cirrhosis. Some- tihies the peritoneal coat only is studded with tubercles of the miliary kind, in various degrees of progress, some being quite vesicular, and others crude. We sometimes meet with a liver of a pale or bright yellow colour, exceedingly soft and tender, containing a large quantity of oil. This is called the fatty liver, and although most frequently seen in phthisi- cal subjects, is yet met with when the lungs are not diseased. A liver in this condition, looks, when superficially observed, of one uniform colour, but when minutely examined there will be seen minute brown, red or greenish spots or lines on a yellow ground. Sometimes the fatty liver does not exceed the natural size; at others it is greatly en- larged. I have seen one so large that its inferior margin extended rather beyond the brim of the pelvis. Another weighed nearly 16 pounds; large sections of this liver floated even in strong alcohol. Sometimes the fatty matter is not universally infiltrated through the liver, but deposited in small masses here and there. A preparation of a diseased liver was presented to me some time ago, in which there was a large effusion of lymph thrown out between the diaphragm and the liver, with adhesions round the edges, which closely resembled a tuberculated liver. Cysts containing hydatids are sometimes found in the substance of the liver, sometimes two or three in number, containing large quanti- ties of these vesicular bodies. Various opinions are entertained re- specting the origin of hydatids, but after an attentive consideration of 352 JAUNDICE. the whole subject, and a minute examination of the bodies themselves, I think they are not animals, but ought to be regarded as diseased pro- ducts like tubercles. JAUNDICE. • It has been already stated, that jaundice is not an invariable attend- ant on hepatitis. It would seem occasionally to depend upon disease of the biliary ducts, perhaps inflammation; we know that it is some- times occasioned by obstructions of various kinds,—as thickening and obliteration of the ducts, and during the passage of gall stones. I have seen jaundice, where no morbid appearance or mechanical cause of obstruction could be discovered after death. It must be confessed, that much remains to be done, both in the physiology and pathology of the liver. Jaundice may be produced, however, by one or other of the following causes: diminished secretion of bile, greatly increased secretion, viscidity of the bile itself, acute or chronic disease of the liver, inflammation and obliteration of the biliary ducts, obstruction from gall stones, and possibly, by spasm of the ducts. Phenomena.—Jaundice takes place, as has been already stated, as an occasional symptom of hepatitis; but sometimes it occurs suddenly in cases where there could have been no acute action, or disorganiza- tion of any kind, and preceded by languor, some degree of restless- ness, diminution of appetite, and other symptoms which attend indi- gestion, nausea, vomiting, and dull pain, or sense of weight in the right hypochondrium. The tongue is generally furred and yellow; the urine is scanty, commonly of a deep yellow, sometimes tinged green, and occasionally like the grounds of porter; bowels slow, and the evacuations whitish. The tinge of the skin is sometimes pre- ceded by a tingling or itching of the whole body, and the colour of the surface is various, from that df pale citron, almost to black. The conjunctiva of the eye partakes also of the colour. Occasionally there is some fever, and the nights are disturbed. Jaundice sometimes comes on insiduously; at others, suddenly. Thus 1 have known a man to sit down to dinner in tolerably good health, and be soon obliged to re- tire, from feeling indisposed, with his whole surface suddenly tinged; the first circumstance which excited attention, was a remark which fell from himself, that the table-cloth was of a greenish colour. This obser- vation leads me to remark, that I have known several individuals who saw every object discoloured. GALL-STONES. 353 [In other instances persons are jaundiced for a long time without any sensible inconvenience, the disease at last passing off spontaneously. The icterus infantum or yellow gum of children, is not uncommon at an early period after birth. It is attributed by Dr. Stokes to some particular irritation of the alimentary canal, derived from the sudden stimulus of the mother's milk. This affection generally subsides without the aid of medicine.] Treatment.—The treatment of jaundice is not well understood. When it accompanies disease of the liver, it must be treated as a symptom; if it seem to proceed merely from functional derangement, the warm bath, one or two emetics, and continued laxatives, should be employed, together with a gentle course of mercury. If there be pain, the application of leeches may be necessary, conjoined with counter-irritation. Great attention must be paid to the diet also, which may be more or less antiphlogistic, according to the urgency and duration of the symptoms. The nitro-muriatic acid bath has ap- peared to be serviceable in many cases. GALL-STONES. As long as gall-stones remain in the bladder, they seem to.be pro- ductive of little annoyance. I once found two hundred and forty in the gall-bladder of a subject, whose history was not known; but on several occasions, I have met with them after death, in which no sus- picion of hepatic disease had existed. Sometimes there is only one calculus, which fills, or nearly fills, the gall-bladder; and I owe a very splendid preparation of this kind to the kindness of Dr. Combe and Mr. Cheyne, of Leith. Gall-stones create pain, it would appear, only when they are in the act of passing towards the intestine. Under such circumstances, the patient is seized with violent paroxysms of pain, during which his sufferings appear to be as great as any human being can well endure; he ascribes his sufferings to spasms. The abdomen is sometimes pain- fully distended by flatus; it is very curious, however, that the pulse frequently remains quite natural, although sometimes it is rather accelerated. Treatment.—We have to direct our attention, in this case, to moderate symptoms. Sometimes bleeding will be productive of relief; in others it does not seem in the least to mitigate the patient's sufferings; but I conceive it to be good practice to open a vein, in a strong, ple- Vol. I.—45 354 INFLAMMATION OF THE SPLEEN. thoric person. The warm bath, and hot fomentations, are to be fre- quently employed. Large doses of opium are to be exhibited, and the bowels must be carefully and daily attended to. It may be men- tioned also, that leeching and cupping are sometimes necessary. [The emetic treatment recommended by some authors is worse than useless. If, by vomiting, a gall-stone could.be forced into the cystic duct, the latter would be much more likely to rupture, than to dilate to the ordinary size of these concretions.] INFLAMMATION OF THE SPLEEN. It is not easy to determine when the spleen is inflamed, indeed I should say almost impossible; for when found diseased on dissection, there have been no symptoms during life, which could be said to in- dicate disease of this organ, more than any other in the abdomen. In all probability this matter is not likely to be discovered, until we know more of the physiology of this organ. It is occasionally found diseased in this country, but still oftener in warm climates, more par- ticularly in situations where intermittent fevers prevail. It has been known to weigh above eight pounds; sometimes it is hard; but most generally we find it, when diseased, soft, like a coagulum of blood; it is in such circumstances that the erectile tissue is best seen, a fine specimen of which is in my museum. The spleen, like the liver, is also subject to the formation of tubercles, both in its substance and capsule. In two or three cases of tuberculated spleen, which were examined minutely, I found the tubercles almost spherical, each in- closed in a capsule. Some time ago, a preparation was presented to me of a large ab- scess in the spleen, the walls of which were partly formed by the stomach and diaphragm. In the centre of the abscess, a portion of spleen, the size of a nut, was found quite detached. In the thorax, the pleura covering the corresponding part of the diaphragm was in- flamed, and the inferior surface of the right lung adhered. In this case there were no symptoms to show that the spleen was affected. The patient died after amputation of the leg, which was performed , with great reluctance, after the occurrence of mortification, as the only chance of prolonging life—extensive diseases of the arteries was dis- covered. There is a splendid dried preparation in my museum, showing the state of parts. Inflammation of the spleen is said to be recognized by heat, fulness, INFLAMMATION OF THE SPLEEN. 355 and tenderness in the proper region, with pain on pressure; for in-, stance, Cullen has given the following definition: "Pyrexia, tension? heat, tumour, and pain in the left hypochondrium, increased by pres- sure, without any signs of nephritis." Discharge of livid blood from the stomach and bowels has often been observed during life, in cases where extensive disease of the spleen was afterwards discovered on dissection; but the same thing happens from other causes. Treatment.—In India, it is alleged, the native doctors treat en- larged spleen by external irritation, acupuncture, and scarifications. General and local bleeding, the warm bath, laxatives, and blisters, are to be had recourse to, as the urgency of the symptoms demand. Pain is to be allayed by opiates.* * In proper order, diseases of the pancreas ought now to be described; but as affections of this organ are obscure, and as I am not aware of any symptoms by which they can be detected, I shall take the liberty of passing over the subject. \ PART II. DISEASES OF THE ORGANS CONNECTED WITH THE RESPIRATORY SYSTEM. CHAPTER I. GENERAL REMARKS ON DISEASES OF THE RESPIRATORY SYSTEM. In approaching the subjects which are to be treated of in this part of the work, I gladly seize the opportunity of expressing the greatest admiration of the talents and powers of observation of the late M. Laennec, and of acknowledging that he is the individual of this age to whom the science of medicine stands most deeply indebted. I know not which to admire most,—the extreme patience with which he carried on his investigations in diseases of the chest, or the zeal and tact which he displayed in surmounting the obstacles which must have daily come in his way. The diseases of the chest were once the opprobium of medicine; and although we are still liable to be mistaken, yet by percussion and auscultation, we are enabled to judge correctly of the nature and seat of some affections, which otherwise would be mere matter of conjecture. It is scarcely more than half a century, since Avenbrugger sug- gested the probability of ascertaining the state of the organs within the thorax more perfectly, by percussing the chest with the points of the fingers. M. Corvisart translated Avenbrugger's Treatise into French, and subsequently brought the practice of percussion into ge- neral use and great repute. It must be confessed, however, that per- cussion is a much less satisfactory practice than auscultation, either with or without the stethoscope, which instrument is the invention of Laennec, and which is now too well known to require any description in this work. A great deal of opposition has been made, and many frivolous ob- jections have been urged, against the employment of auscultation, principally by three classes of practitioners. 1*/, Those who are too well employed, and who have not time to learn any thing new. 2dly, Those who are dull of hearing, or devoid of the power of discriminat- 360 GENERAL REMARKS ON DISEASES ing between sounds which have some resemblance to each other. 3dly, Those who are too indolent or too old. With respect to the first class, I need not say much, as no observa- tions of mine will improve such medical men, by inducing them to pay more regard to the science than to the trade of the profession. But as to the second class, I have only to observe, that it is too bad for men who are deaf, to decry the employment of a means which is found to be so advantageous in practice; and the only method by which they can be silenced, is for others to state their defect,—a task, which, though ungracious, I shall not shrink from performing in re- spect to those whose statements are likely to influence the too numer- ous "herd of imitators" in the profession. In this class, there are some who can hear perfectly well, but who, from the want of what is called a musical ear, are incapable of discriminating sounds, in the same manner as some are unable to detect the difference between a hard and a soft pulse, or a full and a sharp pulse; or as others who, from a defect in the organs of vision, cannot see any thing twenty yards distant. Such individuals, then, will never be capable of avail- ing themselves of this additional means of investigating diseases of the chest; but they have no right to prejudice others in the profession, who are perhaps too happy to avail themselves of any excuse which is likely to save trouble. In the third class of objectors, I have placed the indolent and the aged. With respect to the first of ■ these, I have to remark, that the public have not so much to complain of the igno- rance of medical men, as their indolence and want of zeal; and it is as difficult for a camel to pass through the eye of a needle, as to make an indolent physician active and zealous; therefore it is not to be wondered at, that they should advocate the advantages of remaining ignorant As for many of the aged opponents, they act, no doubt, upon the principle which is observed in old dogs, of not learning new tricks. Before quitting this unpleasant part of the subject, it is proper to impress on those who are fond of indulging in sarcasms against the cultivators of pathology, that ridicule is not argument; and that per- fection is scarcely to be expected from auscultators, any more than from others in the profession. It is also very unwise in any lecturer to decry auscultation, and to bring forward solitary instances of mis- takes made by those who use the stethoscope, or pretend to use it, in the investigation of diseases of the chest. It is not very prudent in any one to run the risk of instilling bad principles into the minds of students, by recommending them to make a show of using the stetho- scope in practice, and " thereby pretend to see as far into the heart of OF THE RESPIRATORY SYSTEM. 361 a stone as their neighbours." What would be said by such an indi- vidual, if the mistakes made by medical men in practice, were brought forward by those inimical to the profession, in proof of the inefficacy of physic and surgery! I have seen the wrong leg amputated by mistake, and the operation of lithotomy has been frequently most cruelly bungled; yet no one is entitled, from the knowledge of many such facts, to say that surgery is altogether useless, or that there are not some clever surgeons. Some individuals have stated objections against the use of the steth- oscope; they say it requires a lifetime to arrive at any thing like per- fection. I have already shown that it requires great patience and good ears to learn it at all, and that those who possess neither the one nor the other, will never be able to use it advantageously. But if the difficulties of any task were allowed as an argument against making attempts to overcome them, it may be asked, what would become of all the sciences? They also state, that it is indelicate to examine the chest of a female with this instrument under any circumstances; and that it frequently cannot be done, in consequence of the fatigue it occasions to the patient. With respect to the first, I have to observe, that it is an ob- jection which I should have expected from one individual only in the British Empire—Sir Anthony Carlisle. I feel convinced that every professional man of experience will join with me in the following statement, that fewer objections are started by females possessing deli- cate and innocent feelings, to any kind of examination which their medical adviser may think it necessary to propose for their advantage, than by those who unfortunately are differently constituted. It is to be lamented that this objection is brought forward more in the spirit of special pleading, than with a view to benefit either science or good morals. It may be maintained, however, with truth, that the exami- nation may be made in such a manner as not to occasion the slightest blush, as the patient need never be exposed, the different sounds of respiration being sufficiently audible for all useful purposes, through the texture of an ordinary night-gown. Instead of meeting with ob- jections on the part of females, it has always occurred to me to observe not only a readiness, but an anxious desire, that the investigation of the nature and seat of any disease in the chest should be carried out to the most complete elucidation. Cases no doubt occur, in which it is inconvenient and painful to move the patient much; but these are com- paratively rare, and must be so far disregarded when life is at stake. 1 shall now turn to a more agreeable part of the subject, by shortly Vol. I.—46 362 GENERAL REMARKS ON DISEASES stating a few cases, showing the advantages derived in actual practice from auscultation. A few years ago, I was requested to see a patient who had been under the care of several medical men, and by way of giving me every necessary information, his friends put me in possession of all the recipes which had been recommended;—they would have made a moderately-sized quarto volume. At one time, it was supposed that he had stomach complaint, and all known tonics were prescribed; at another, it was supposed to be scrofula, for which he took large quantities of the muriate of lime; at last, he was suspect- ed to have diseased liver, and he got large quantities of mercury, and was several times completely salivated. Upon applying the stetho- scope, 1 discovered a cavern in the superior lobe of the right lung, and was doubtful whether another did not exist in the left. Next day, I had the advantage of a consultation with Dr. Scott, whose superior knowledge of the diseases of the chest and stethoscopic tact, I am happy to have this public opportunity of acknowledging. He was merely asked to see a patient with me, without knowing the result of my previous examination, which he confirmed, with this addition, that he had also no doubt of the existence of a cavern in the left lung; and it was afterwards proved to be correct. A remarkable case oc- curred to me some years ago, at a time when I was only beginning to make some progress in the use of the stethoscope. A man presented himself, with many of the ordinary symptoms of indigestion, and without a single sign indicative of disease of the lungs. I examined him carefully with my ear, with a view of perfecting myself in the natural sounds elicited by respiration, and the tones of the voice, when, to my astonishment, I thought I discovered a small cavern in the superior lobe of one of the lungs. At that time, Dr. Wavel, an excellent stethoscopist, was a pupil at the dispensary. He was re- quested to examine the man, without being made acquainted with my suspicions. Upon comparing notes, he was of the same opinion. It was subsequently discovered that the man coughed a little in the morning, but not so much even as to attract his own attention; upon dissection, some months afterwards, our diagnosis was fully verified. Dr. Henry of Manchester, and others, will not forget the case 1 had occasion once to examine with him, in which we discovered empyema of the left side of the thorax, which had been treated for disease of the heart because the pulsations were felt to the right of the sternum, in- stead of the left. By auscultation and percussion, we were enabled to state most confidently that there was extensive effusion, which pushed the heart to the other side of the chest. The patient did not survive OF THE RESPIRATORY SYSTEM. 363 above a fortnight afterwards, and the correctness of our opinion was filly proved, by the existence of an immense effusion in the left side of the thorax, amounting, I believe, to twenty or twenty-six pounds of fluid, with large masses of lymph. ' Liver complaints are often confounded with diseases of the lungs, in ivhich it is of the greatest consequence to the patient, that the physician mould be able to form a proper diagnosis, which he cannot do in many ;ases without the assistance of ascultation and percussion. A case of this kind once fell under my notice. A physician treated a patient during some time for a pulmonic complaint, without knowing its ex- act nature or seat, which he could not fail to have discovered, had he been able to use the stethoscope. After a little time, the patient complained of uneasiness in the abdomen, and the liver was felt rather prominent on the right side, but pressure did not aggravate the symp- toms. It then came out that the man had been in India for several years, and as that was the case, it was supposed that he could not fail to have drank plenty of arrack, and consequently to contract an affection of the liver. He was accordingly salavated over and over again, but the enlargement continued to increase; and it may be briefly stated, that the man died. Upon dissection, his liver was perfectly sound, and it was found that the protrusion was occasioned by immense effusion into the left side of the chest, which pressed down the diaphragm, and encroached upon the abdomen. By auscultation and percussion, we shall be always able to discover the existence of collections of fluid in the chest, which by ordinary symptoms cannot be ascertained. Dr. George Gregory, a late writer on the practice of physic, in his article on hydro-thorax, or dropsy of the thoracic cavity, (627, ed. 1825,) states as follows: " The diagnos- tic symptoms of this form of dropsy are very fallacious. Sometimes we are confident of finding water in the thorax, when that cavity is perfectly free from disease. At other times, we observe the thorax full, when we had no suspicion of the complaint existing." I have no doubt, after writing this paragraph, the author applied him- self most assiduously to the acquirement of stethoscopic knowledge, without which no man can treat diseases of the chest with any con- fidence. It is well known, that there is a great resemblance between the or- dinary symptoms of inflammation of the pleura, and a painful affection of the intercostal muscles, which is called pleurodynia; the resem- blance is so great, that it is impossible to distinguish the one from the other without the use of the stethoscope. Not long ago, I had three i 364 GENERAL REMARKS ON DISEASES such cases within a short space of time; only one proved to be pleu- risy, and that was the one in which I least expected to find it, from the slightness of the ordinary symptoms. I have seen many remarkable cases of chronic inflammation, and I believe extensive ulceration in the wind-pipe, which the ordinary symptoms announced to be the most hopeless cases of phthisis pul- monalis;—there was cough, expectoration tinged with blood, emacia- tion, debility, rapid pulse, with bad feverish nights, attended by pro- fuse perspiration. By the sound of the respiration, and the resonance of the voice, I was enabled to assure myself that the lungs were as yet sound, and they were all cured by means to be afterwards de- scribed in the proper place. Every year 1 see several cases of chronic bronchitis, which have been mistaken for phthisis, many of which were cured or relieved by the appropriate remedies, which must have terminated fatally if managed as cases of phthisis. In the treat- ment of inflammation of the substance of the lungs, it is of the utmost consequence to be able to tell whether the disease be extensive or not; whether it be in the first stage, that of active sanguineous engorge- ment; or in the second, that of solidification; whether the disease is advancing or declining, which can be done by no other means than auscultation and percussion. It has already been attempted to be shown, of how much advantage it is to sound the chest in cases of fever. Much injury it is to be apprehended, will result for some years to come, from individuals pretending to use this instrument, and pro- nouncing confident opinions as to the nature and seat of diseases, who are unacquainted even with the natural sounds of respiration, and who, as 1 have often seen, do not really know how to hold the stethoscope. Few individuals can acquire the power of using the instrument ad- vantageously from books, without the personal assistance of some one already instructed; and I have known several gentlemen give up the task as hopeless, because they could hear nothing at all, but who resumed it, upon being properly assisted and instructed. On the other hand, candour compels me to mention, that much mischief has been done by some able stethoscopists pretending to do too much; according to them, auscultation is infallible; but that this is not to be expected from any human invention applied for the pur- pose of investigating or curing diseases, I need not waste time to prove. That it is a great assistance, as an additional means of diagnosis in diseases of the chest, no man possessed of the spirit of truth, who has fairly given it a trial, or who has followed the practice OF THE RESPIRATORY SYSTEM. 365 of those who can avail themselves of auscultation, will deny. I main- tain, without the fear of contradiction, that perhaps one of the greatest advantages to be derived from auscultation, is that which enables us to obtain negative proof, in cases where we have failed in discovering positively the seat of the disease. For example, if a medical man be called to a case which has either been pronounced to be consumptive, or in which a doubtful opinion has been given, it is truly delightful for all parties, if he be able to give a positive assurance that the lungs are not affected, although he may not be able to tell exactly the seat of the disease. Some medical men allege, that they can discover every condition of the lungs, quite well enough for all practical purposes, by ordinary symptoms; therefore I shall now take a view of these symptoms, for the purpose of showing the fallacy of this statement. The follow- ing symptoms are supposed to denote inflammation of the lungs, in the most satisfactory manner: cough, dyspnoea, pain in the thorax, quick and strong pulse, being softer, however, when the bronchial membrane and substance of the lungs are inflamed than the pleura. When these symptoms exist, they are supposed to be peculiar to in- flammation of the lungs; that is to say, when they exist, inflammation is present, and when they do not exist, the disease is absent. Expe- rience enables me to state, that not one of these symptoms, or all taken together, indicate inflammation of the lungs in any of its tex- tures, and that inflammation may exist without any of them being well marked; hence it is, that physicians are so often astounded with the appearances on dissection, which they did not anticipate from the mildness of the symptoms; and hence it is, they too often decry the usefulness of morbid anatomical inquiries. Cough is not peculiar to disease of the lungs; it may be produced in a violent degree by any kind of irritation about the larynx, epi- glottis, and even the pharynx: mere excitement of the circulation frequently produces cough, as well as diseases of the heart. I shall afterwards prove, that in some of the most hopeless cases of inflam- mation of the lungs, the patient cannot cough, in consequence of which the danger is greatly increased; therefore cough cannot be said to be peculiar to inflammation of the lungs. Dyspnoea is as frequent a consequence of disease of the heart, as of the lungs; mere excitement in the circulation will produce dyspnoea. One of the most distressing cases of dyspnoea which I ever had the misfortune to witness, dissection proved to depend on an enlargement of the gland, which fills up the angular space at the bifurcation of the 366 GENERAL REMARKS ON DISEASES bronchial tubes. From a mechanical cause, also, oedema of the inferior aperture of the glottis frequently produces a fatal dyspnoea. In many cases of extensive and severe inflammation of the bronchi, after free expectoration, the dyspnoea subsides so completely, that should a symptomatical physician happen to make his visit at that period, he will pronounce the patient to be convalescent, when perhaps within an hour or two he will be no more. Even in pneumonia, if the in- flammation be confined to a small part of one lobe, which it frequently is, there is little dyspnoea; and the whole of one lung may be de- stroyed by chronic inflammation, without occasioning much difficulty of breathing, if the disease go on very slowly. With respect to pain, nothing is more deceptive, for there may be severe pain in the chest without inflammation, as has been already stated with regard to the affection denominated pleurodynia. In bron- chitis there is little or no pain; in pneumonia the pain is generally little marked; and, contrary to the statement made in all systematic works respecting the severe pain in pleuritis, experience enables me to state, that it may go on most extensively, even to a fatal termina- tion, without much complaint; hence we often see on dissection, most extensive adhesions of long standing, between the pleura pulmonalis and costalis, in individuals who had never been known to experience any very serious indisposition till their last illness. It has already been shown, that a hot skin is not an invariable phe- nomenon in inflammation; and the same remark may now be made with respect to inflammation of the lungs; indeed, in bronchits the heat of skin is frequently below par. It has also been stated, that the pulse cannot be depended upon as a certain indication of inflammation; and in addition to the remarks already made in this work, I may now state, that hypertrophy of the left side of the heart frequently produces a strong bounding pulse, and also dyspnoea, when there is no inflammation going on in any organ of the body; and on the other hand, dilatation of the ventricle will produce a weak, soft pulse, at a time perhaps when every form of pneumonic inflammation is going on most rapidly. All Cullen's definitions, in the sixth chapter, which treats of pneu- monic inflammation, are therefore erroneous, as well as the following paragraph, p. 335.) " Pneumonic inflammation, however various in its seat, seems to me to be always known and distinguished by the following symptoms:—pyrexia, difficult breathing, cough, and pain in some part of the thorax." It will be admitted that Cullen was at least as wise, talented, and observant as any of his symptomatical OF THE RESPIRATORY SYSTEM. 367 brethren of the present day; yet he confesses that he could not ascer- tain the seat of the disease by the ordinary symptoms, as will be seen upon perusing the 334th paragraph. " Under this title I mean to comprehend the whole of the inflammations, affecting either the vis- cera of the thorax, or the membrane lining the interior surface of that cavity; for neither do our diagnostics serve to ascertain exactly the seat of the disease, nor does the difference in the seat of the disease exhibit any considerable variation in the state of the symptoms, nor lead to any difference in the method of cure." Proving by the latter part of the paragraph, that he must have been an indifferent practi- tioner, as the inflammatory affections of the lungs require a different treatment in each stage; bronchitis demands a different plan from pleuritis, and pneumonia from either of the others. I venture there- fore to predict, that in a few years, practitioners, even those who now ridicule auscultation, will be compelled, in self-defence, to have re- course to this additional means of diagnosis, or they will lose their practice. CHAPTER II. DISEASES AFFECTING THE MUCOUS MEMBRANE OF THE AIR-PASSAGES. Under this title, I shall treat of catarrh; Bronchitis; inflammation of the larynx; croup, and hooping-cough; together with the affection which is sometimes known by the term crowing disease, at others spasmodic croup. CATARRH. When a patient is seized with chilliness, followed by sneezing, slight fever, impaired appetite, hoarseness, occasionally loss of voice, and cough, he is said to have catarrh, or a common cold. The bowels are generally out of order, and he has an exacerbation at night The cough is sometimes slight, at others severe. A slight degree of wheezing is heard, and the disease has a salutary termination in a few days, by expectoration of mucus, which is discharged by occasional fits of coughing. Sometimes the disease is confined to the mucous membrane of the nose and frontal sinuses, and is known by the vulgar denomination'of " cold in the head." When catarrh is a general complaint, attended by considerable prostration, and constitutional symptoms which are otherwise slight, the disease has been denominated influenza. But it must be confessed, that after a careful perusal of all the accounts which have been given of the various epidemics of the disease called influenza, I am unable to draw pathological conclusions as to the exact nature and seat of the affection. This part of the subject must therefore be considered un- decided, till further observation by auscultation and percussion enables us to determine. In considering the pathological difference between catarrh and bron- BRONCHITIS. 369 chitis, it must be recollected, that in both, the same membrane is af- fected, but in different parts; I imagine, that in the former, the dis- eased action is a very slight sub-acute inflammation, affecting the mu- cous membrane of the nose, frontal sinuses, the larynx and trachea. Slight cases of inflammation of the membrane lining the bronchial tubes, frequently pass also by the name of catarrh, instead of bronchitis. Causes.—Exposure to cold, particularly alterations from heat to cold, with insufficient clothing, is the chief cause of this complaint, as well as bronchitis. It would appear to be of no consequence how cold the air we breathe is, provided the surface of the body be pro- perly protected; hence I believe, that bronchitic affections are, com- paratively, of less frequent occurrence in very cold regions than in this variable climate. Treatment.—We are seldom called upon to treat a simple catarrh, unless severe constitutional symptoms have been excited by some ac- cidental cause, as constipation; a hard fit of drinking; or a load of indigestible food in the stomach; when an emetic, the antiphlogistic regimen, a proper course of laxatives, diaphoretics, and confinement lo the house, will generally be all the treatment found necessary. It may be mentioned, however, that the warm bath ought to be recom- mended when it can be conveniently obtained. We are sometimes consulted in consequence of the inflammation having extended into the air-tubes, and having become aggravated by exposure in cold damp weather, when we shall frequently find that the disease has already made great progress. This is particularly the case with the children of the poor, who are badly fed and clothed, and for whom little permanently effectual can be done. BRONCHITIS. I shall treat of bronchitis in two forms, the acute and chronic. Ancient physicians appear to have been unacquainted with the na- ture and seat of bronchitis, although many of them have recorded cases of the disease. Sydenham has described the affection, as it sometimes occurs, under the title peripneumonia notha; and it will be found, that most authors since his time have copied his description, still remaining ignorant of the nature of the affection. Hoffman's catarrhus suffocativus; Lieutaud's fausse peripneumonie, and ca- tarrh suffocante; Sauvage's rheuma catarrhal, do not differ from Sydenham's peripneumonia notha. Morgagni, who may justly be Vol. I.—47 370 BRONCHITIS. regarded as the first, and one of the most successful cultivators of morbid anatomy, seems to have been in some measure aware of the nature of the chronic form of this disease, and he has given ample proof, in his second book, that he knew it had been confounded with phthisis. Cullen has given a good description of the symptoms of the disease, under the term used by Sydenham, peripneumonia notha, but has not added any thing to our knowledge upon this subject; and more- over he entertained erroneous notions of the true nature and seat of the disease. The same remark may be made respecting the later work of Dr. Mason Good. The profession stands indebted to Dr. Badham, now professor of the practice of physic in the university of Glasgow, for pointing out the nature and seat of the disease in a little work he published on bron- chial inflammation many years ago. Before the appearance of this work, the disease was very imperfectly understood by the best phy- sicians of the day; and even now, it is surprising that bronchial in- flammations are so much neglected, particularly in fevers, rheumatic, gouty, and erysipelatous affections, as well as in the course of surgical practice. Pure surgeons (by which I mean surgeons who pride themselves upon their powers of cutting, and boast of their ignorance of every thing medical,) should be told, that they frequently submit patients to capital operations, who are at the same time labouring under exten- sive inflammation of the mucous membrane of the lungs, perhaps in a sub-acute form, and which does not give rise to symptoms sufficiently violent to attract the attention of their surgical minds. They become worse from the progress of the disease, or in consequence, very pro- bably, of the agony and fright experienced during the period of a painful and tedious operation. The pulse becomes weak; the skin cool; the face either very pale or somewhat livid; and the wound of course, puts on an unhealthy appearance,—adhesion by the first in- tention does not take place, and at the first dressing, the lips of the wound are found gaping, discoloured, with a foul discharge. In such cases patients are too often drenched with wine and bark, and crammed with stimulating food, under the idea of preventing debility and pu- tridity. Notwithstanding these remedies, the strength fails, and gin and brandy are in vain had recourse to: the destruction of the parts in the neighbourhood of the wound takes place, and the patient dies from presumed gangrene, which is too frequently attributed to the bad air of the hospital. I do not mean,to assert, that all cases which BRONCHITIS. 371 go wrong after surgical operations, are owing to bronchitic inflamma- tion; but I maintain that many are, and particularly the cases in which erysipelas follows. But I will say more on this subject when treating of erysipelas in the second volume of this work. Symptoms of Acute Bronchitis.—The symptoms excited by in- flammation of the mucous membrane lining the bronchial tubes, vary according to the severity and extent of the inflammation. The tubes of one lobe may be affected, when the symptoms will be slight; the inflammation may be still more extensive, affecting perhaps both lungs, and the symptoms will be slight also if the diseased action be but moderate. The acute form of the disease, which I am now to describe, com- mences with some degree of chilliness, succeeded by pyrexia, hoarse- ness, dyspnoea, and a dry cough; tightness, or sense of stricture in the chest, and oppression at; the praecordia; prostration of strength; loaded tongue and costive bowels. An exacerbation is almost always observed at night. In a day or two, expectoration takes place, which relieves the patient for the time; the respiration, however, becomes more difficult, but the cough bears no proportion to the dyspnoea; the tightness about the chest is increased, along with a sense of suffoca- tion, when the pulse becomes very rapid. The deadly paleness or lividness of the lips and cheeks becomes more apparent; the counte- nance more and more anxious; and the patient frequently requests to be raised, and to have more air. A loud wheezing may now be heard, even at a distance from the bed-side. The voluntary muscles of re- spiration are brought into play. The patient becomes insensible; rattling is heard in the throat; the extremities and face become livid, a cold perspiration bedews the skin, and death soon closes the scene. Sometimes cerebral symptoms take place, and headache is much complained of, which may be attributed to impeded circulation in the head. The wheezing is produced by the air passing through the dis- eased secretion in the air-passages, and may be heard by placing the ear to the chest, long before it becomes so severe as to be distinguish- ed by any other means. The cases of acute bronchitis most to be dreaded, are those in which the oppression in the chest being more or less considerable, there is neither heat of skin, pain, nor much febrile movement in the pulse. In fact, these three symptoms may be said to be below par; no alarm is taken till suffocation is threatened, or some organic lesion has been produced; and when at length the signal of distress is displayed, it will be found too late to save the patient. 372 BRONCHITIS. The disease is very fatal in infancy and childhood, and I shall now mention its course and progress at these periods of life. It commences in the same manner as in adults, like a common cold. The breathing becomes oppressed; all the voluntary muscles connected with respira- tion are called into play; the shoulders are in constant motion as well j as the nostrils, and the abdomen becomes more prominent, by the in- creased action of the diaphragm during inspiration. Sore throat fre- < quently accompanies the disease, and the child suffers so much pain J during the act of coughing, that an attempt is made to suppress it; I wheezing soon takes place, which is more decided than dyspnoea; ex- J pectoration is generally followed by mitigation of suffering, which continues for a longer or a shorter period, till more phlegm is formed. \ The mucus secreted in the air-passages, is frequently discharged by -l spontaneous vomiting, exactly as occurs in hooping-cough. Children \ under four or five years of age, can rarely be made to spit up the j phlegm, unless assisted by the act of vomiting; but they swallow it H after it has been discharged from the air passages. Children refuse 1 food, but drink greedily until the disease is far advanced, when they cannot take a long draught from want of breath. An infant at the breast sucks pretty well during the first stage of this affection; but subsequently, although it seizes the nipple with avidity, it cannot suck for any length of time together, perhaps not for more than ten or fif- < teen seconds, when it will be observed to bite the nipple very forci- < bly, and discontinue sucking; it will cry, and be observed to throw its head back quickly, and will continue in this position for some time, { even after the cough has produced the expulsion of the mucus.* If the disease remain unsubdued, the dyspnoea increases; the face shows the usual marks of impeded circulation; the surface becomes cold; the extremities sometimes swell, and the child dies from suffocation. Very often, the sound of the voice and the cough are as shrill as in the croup, with which disease bronchitis is sometimes confounded. Dr. Hastings, in his very excellent work on the lungs, has given a concise account of a variety of acute bronchial inflammation, to which young children are peculiarly subject, which I have often had occa- sion to see. Although more dangerous, the symptoms are not of cor- responding severity; in truth, it is a sub-acute inflammation of the bronchial membrane throughout the whole extent of both lungs. No severe symptoms are excited as long as expectoration continues free, and is discharged with ease; but should the mucus by any accident * This position seems to facilitate the passage of air into the lungs. BRONCHITIS. 373 increase, the cough at the same time ceasing, speedy death from suffo- cation inevitably follows, unless vomiting be excited, which seems to have the effect of emptying the air-passages of the secretion. Other cases take an unfavourable turn, by the inflammation becoming more active, from some accidental circumstance, such perhaps as exposure to cold. Cases of this sort are most common in spring and autumn. In the acute bronchial affections of children, there are often consider- able variations in the state of the breathing and the pulse,—the latter depending in a great degree on the former. The breathing for several hours continues free and easy; afterwards it gradually becomes less so; and at last great difficulty takes place suddenly, even so as to threaten immediate suffocation. These exacerbations appear to be owing to three circumstances; 1st, collection of mucus in the bronchi; 2dly, increased circulation through the lungs; and lastly, venous con- gestion. Children so affected, soon fall into a comatose state; the face, which for some days perhaps had bedn quite pallid, now becomes livid, or a dark circle shows itself round the mouth, and the child sinks in the manner already described. In some urgent cases, the fatal event takes place in sixty or seventy hours from the time alarm is taken; the majority of cases, however, are not so rapid, the course of the disease being from five to fifteen days; but when it is protracted, other structures generally become involved, the inflammation spreading by contiguity; and the same happens in adults. In all affections of the lungs, particularly in the acute, the bowels become constipated, and the evacuations fetid. The expectoration in bronchitis is at first scanty and viscid, parti- cularly so in the most acute cases; by degrees it becomes more copious and less viscid, and therefore more easily expectorated, till at last it is discharged inconsiderable quantity, having the appearance of starch mixed with small bubbles of air, and occasionally streaked with a lit- tle blood. If the case go on well, it gradually diminishes, and be- comes slightly yellow in colour; the patient is troubled with the cough and expectoration in the morning only; at length they cease entirely. Sometimes however, the acute disease runs into the chronic form, which is now to be described. CHRONIC BRONCHITIS. Like other chronic inflammations, this affection sometimes succeeds to an acute attack; sometimes however, it takes place as a slow and in- sidious inflammation of the bronchial membrane. This form of the 374 BRONCHITIS. disease may affect individuals of all ages; but it is most frequently met with in old people, and those who, by occupation, are exposed to the inhalation of dust. It sometimes succeeds also to the eruptive fevers; and frequently co-exists with diseases of the heart. It is occasionally mistaken for phthisis pulmonalis; and is one of the morbid conditions of the organs within the chest, which give rise to the symptoms denonlinated asthma; and is a frequent cause of dropsical affections. When the disease succeeds to acute bronchitis, the fever declines, but the pulse for some time continues frequent; the cough and diffi- culty of breathing continue, but they are always relieved for a con- siderable time, after free expectoration. The patient still has night ex- acerbations and disturbed sleep, which, however, gradually decline with the disease. The expectoration still copious, becomes opaque, yellow, sometimes puriform, and has occasionally a greenish hue; at last it diminishes in quantity. The appetite returns; and although weakened by copious night perspirations, and which take place during the day upon making the least exertion, the patient is sensible of gain- ing some strength. Gradually all these symptoms cease, and some in- dividuals appear to undergo a perfect cure; but in general they are not so fortunate, for during the subsequent part of their lives, an east- erly wind, or a humid atmosphere, occasions a renewed attack; and with many, the same effect is produced by eating indigestible food, or by neglecting the bowels. Now and then, therefore, they become in- disposed; the voice becomes hoarse; the cough short and croupy, with more or less oppression in breathing, attended sometimes by febrile symptoms. In the chronic form of the disease, the expectora- tion takes place in a much shorter time from the commencement of the indisposition than in the acute; sometimes in a few hours; it is viscid at first, but soon becomes copious, and the patient is relieved by the discharge. One attack leads to another, till at last the individual is generally affected with dyspnoea,—he is almost constantly coughing and spitting, and is unable to lie in the horizontal posture; he feels great difficulty in mounting a stair,—and is said, in short, to have an habitual asthma. I have stated, that Morgagni, and other old writers, seem to have been well acquainted with the phenomena of chronic bronchitis. We are told, for instance, by Morgagni, that Valsalva examined the body of the Bishop of Imola, who was supposed to have died of phthisis, having had considerable expectoration before his death; but he did not find tubercles, or any other disease, in the structure of the lungs. In the acute and chronic forms of bronchitis, cases now and then BRONCHITIS. 375 present themselves, in which the expectoration is very small in quan- tity, so as sometimes scarcely to be perceived, when the disease has been denominated "dry catarrh," and "dry asthma." Stethoscopic signs of acute and chronic Bronchitis.—Percussion affords little information in any of the forms of bronchitis; but auscul- tation enables us to determine the stage and extent of the disease, even before the symptoms are completely formed.* In the first stage of in- flammation of the mucous membrane of bronchi, it becomes somewhat swollen, probably from the increased quantity of blood in its vessels, and its surface dry; upon applying the ear to the chest, either with or without the cylinder, instead of hearing the natural soft murmur of respiration, a louder sound strikes the ear; sometimes like a snore, at other times sibilous, or resembling what may be called a somewhat harsh, brazen sound. It is more sonorous, and flatter, according to Laennec, in proportion as the mucous membrane is swollen, and its surface dry; and he states,—" When so strong as to resemble the pro- longed scrape of the bow on a large violoncello string, or the note of the wood-pigeon, there are usually redness and swelling at the bifur- cation of some of the principal bronchia."* As the disease advances, it has been stated that wheezing takes place, which is produced by the passage of air through the diseased secretion in the bronchial tubes; this is called " the mucous rale or rattle," which in many cases is so loud, as not only to be heard on entering the room, but to be felt by placing the hand upon the chest, which experiences a vibration during each inspiration and expiration. In some cases we may find the respiration suspended in a portion of the lung for an hour or two, which becomes restored after a severe fit of coughing. In this case, percussion may be of some assistance to us. These occasional interruptions to respiration, are owing to a plug of tenacious mucus or lymph closing up the entrance of the tube; or it may be completely filled with viscid matter. In chronic bronchitis, attended with expectoration, we have in some cases the same mucous rattle over the whole thorax. When there is no expectoration, then we hear pretty loud snoring, which is denomi- nated the "dry sonorous rattle;" occasionally it resembles the cooing of a wood-pigeon; and sometimes at the very top of the inspiration, a sound is heard like the chirping of a bird. Occasionally a prolonged hissing sound is perceived, flat or sharp, of greater or less intensity, called the dry "sibilous rattle," which has a resemblance also to the chirping of birds. And sometimes a sound * Forbes's Translation, p. 67. 376 BRONCHITIS. is heard, which Laennec has aptly compared to that which is "emitted by suddenly separating two portions of smoothed oil stone, or by the action of a small valve." In truth it is what may be denominated a clicking sound. Laennec states, that these sibilous sounds are proba- bly owing to minute portions of very viscid mucus, obstructing more or less completely the small bronchial ramifications, or to a local con- traction of the small tubes, from thickening of their inner membrane. Appearances on dissection, and pathological remarks.—On open- ing the thorax, we generally find that the lungs do not collapse, if the individual have died from suffocation in consequence of the engorge- ment of the bronchi with matter. In some cases, in which the cough has been severe, the surface of the lungs looks white, as if coated with a layer of coagulable lymph; but on examining this appearance more closely, it is found to depend on an effusion of air beneath the pleura, forming that peculiar condition termed emphysema. On opening the trachea, it will sometimes be found filled with matter; but in general, it is merely coated with thick, viscid mucus, which, when wiped off, shows some degree of redness, increasing towards the bifurcation. The bronchial tubes are found more or less filled with matter, which is sometimes like mucus or pus; occasionally it has a mixed appearance, which is appropriately denominated maco-purulent; sometimes it is tinged With blood, and looks reddish. This secretion is found occasion- ally even in the air-cells, distending them, giving a uniform granular appearance to the whole of the part affected; and there can be no doubt, that this is one way in which tubercular formations take place in the lungs. Upon washing away the puriform matter, the mucous membrane itself will be sometimes found intensely red; at others, of a dark red, like lees of wine; the discolouration will be found to in- crease in the course of the ramifications. The texture of the mem- brane is observed to be thickened, more especially in chronic inflam- mation. Ulcerations are frequently seen at the great bifurcation, rarely lower down. The pulmonary substance will be found more or less congested with blood, and sometimes oedematous. These are the ordinary appearances observed in bronchitis; the following are to be regarded as accidental. False membrane is sometimes found in the trachea, the same as in croup; the lungs are seen in different stages of inflammation, from active sanguineous engorgement, to complete dis- organization; pleuritic effusions are also sometimes found, and enlarge- ment of the bronchial glands. In the brain we frequently see marks of impeded circulation, sometimes inflammation. In the abdomen, the liver is sometimes found gorged or altered in structure, and the mucous membrane of the stomach and bowels shows various de- BRONCHITIS. 377 grees of vascularity, and even ulceration is observed. These appear- ances in the liver and bowels, are in all probability owing to long-con- tinued impeded circulation through the lungs, and diseased condition of the blood. In chronic bronchitis, we sometimes find considerable dilatation of the larger tubes, which»is perhaps chiefly brought about by long-con- tinued distension,—a remarkable case of which once occurred to me. In this instance, I declared that there was a cavern in the superior lobe of the right lung, which upon dissection turned out not to be the case; but there was immense dilatation of the bronchial tube; thus mistaking bronochophony for pectoriloquy. Another case occurred to Dr. Alison, in which the dilatation was great, and the tubes af- fected numerous. A delineation of the lungs is given by my friend Mr. Spittal, in an excellent work on auscultation, to which 1 can with confidence recommend my readers. In making post-mortem examinations, with a view of discovering the nature and seat of bronchitis, these accidental morbid alterations of structure should be kept in mind, along with the symptoms and progress of the case; because although they may form the most pro- minent appearances on dissection, and are no doubt in many instances the cause of death, yet they are only to be regarded as the effects of the original disease. Nay, sometimes an individual labouring under acute or chronic bronchitis, may have expectorated freely, immedi- ately before expiring in the act of either coughing or vomiting, when we shall find little or no effusion in the bronchial tubes, and some- times very little redness. It is proper to state also, that notwith- standing the attention which has been paid of late years to the pa- thology of the lungs, there is still some ambiguity connected with this subject, evinced by the fact, that dividing the pneumo-gastric nerves in animals produces dyspnoea, change of voice, and effusion into the air-passages. Of all the symptoms, wheezing is one which may be said to be pe- culiar to bronchitis; cough and dyspnoea, it has already been shown, are common to all diseased conditions of the lungs, and not of the lungs only, but of other organs. Some assert, that the wheezing is owing to spasms, but this is not the case; for we find that it is greatest before expectoration takes place, the patient afterwards being pretty free from it till a fresh secretion collects in the air-passages. Dys- pnoea has also by some been attributed to spasms. Reisseissen thinks he has ascertained the existence of circular fibres in the ramifications of the bronchi, commencing at the point where the cartilaginous cir- Vol. I.—48 378 BRONCHITIS. cles terminate. Laennec supposes that he has also proved the exist- ence of these fibres upon branches of the bronchi, of less than a line in diameter; and therefore concludes, that spasmodic contraction of these fibres occasionally produces dyspnoea. I am far from admitting this structure in the present state of our knowledge; but even if it were so, it is of little consequence, when there is an increased quan- tity of mucus in the tubes themselves, offering a sufficient mechanical cause for the phenomenon itself, and for the exacerbations and re- missions, which are so frequently observed in all the forms of bron- chitis. Whatever consequence may be attributed to such a structure, in accounting for the symptoms in some cases of asthma, it is of little practical importance in acute or chronic bronchial inflammation. It has been already shown, how the brain becomes affected during the course of bronchitis, when severe pain in the forehead is often remarked. Some suppose this is owing to inflammation of the mem- brane lining the frontal sinuses; but this is not the case; for if it were, this symptom would be most severe when patients are affected with what is called "a cold in the head:" besides which, it is a different kind of pain. That which proceeds from the state of the membrane in the frontal sinuses is pungent, producing a flow of tears, exactly as when we smell volatile salts. The lividity of the face and lips, and mucous membrane of the mouth, is owing to the want of the usual changes which take place on the blood in the lungs. Treatment of Acute Bronchitis.—This depends exactly upon the period of the disease, the extent of the morbid action, the state of the cough, the expectoration, and the previous health of the patient. Bleeding is certainly not necessary in every case of bronchitis which comes before us, particularly in one that is slight, and confined to a small part of the lung; but if the whole lung be affected, and more especially when both are implicated, bleeding is to be had recourse to early and decidedly. It is a very doubtful remedy when the second stage is far advanced, and highly injurious in the last I know no disease more under management by any remedy, than bronchitis is by bleeding, if performed in the first stage, or during the first part of the second; and there is no case in which the stethoscope is more useful; for without it, this disease may advance through the first stage before it is detected by the ordinary means of investigation. Many assert, that bronchial inflammation will run through a certain course, in spite of every remedy; and so it will, if the inflammatory stage is nearly over before discovered, or if bleeding be not used in a decided manner. Although late bleedings are to be especially condemned in this dis- BRONCHITIS. 379 ease, yet cases do occur, where the lungs become suddenly congested with blood, in which a well timed venesection is of signal service. In the first stage of bronchitis, when both lungs are extensively affected, one bleeding will in general suffice, and we need not be afraid to carry it to syncope, as long as the air-passages are free from mucus; but after it has collected in considerable quantity, and I speak more particularly with respect to double bronchitis, sudden death may be the consequence, by robbing the patient of that strength which is re- quired in coughing to produce expulsion. In bronchitis, we can scarcely ever determine the necessity or the propriety of bleeding by the ordinary signs, because in some cases the disease may be very ex- tensive, without violent symptoms; in others, it may be very slight, and the symptoms very severe, owing, perhaps, to a disordered state of the stomach and bowels, or to some other, perhaps slight cause; and it is of great consequence to know when to desist from further depletion. Cullen, in the 3Slst paragraph, states, that " in case the fever, ca- tarrhal, and pneumonic symptoms, are immediately considerable, a blood-letting will certainly be proper and necessary; but where these symptoms are moderate, a blood-letting will hardly be requisite; and, when an effusion is to be feared, the repetition of blood-letting may prove extremely hurtful." Which statement sufficiently proves that he must have practised with great uncertainty. We are to decline bleeding, not because we are afraid of producing effusion, but when we know that it already exists in considerable quantity in both lungs. Leeching or cupping is very seldom serviceable in this disease;* but in children who are too young to be bled at the arm, leeches are to be applied; and we have sometimes great difficulty in determining the number,—suffice it to say that it is better to apply few when in doubt upon the subject, and to repeat the operation in a short time. If consulted early, we can make a near approach to the effects produced by general bleeding, by applying a considerable number of leeches at one time, and stopping the discharge soon, so as not to allow the body to be slowly drained of blood; but even in children, it is far better to draw blood from a vein, when it is practicable. I speak from the result of considerable experience. Next in point of importance to blood-letting, in pulmonary inflam- mation, stands antimony, as a counter-stimulant; this was well known, [* Experiense has led the physicians of the United States to the converse of this opinion: after general bleeding, local bleeding, especially by cups, is justly esteemed one of our most efficient resources in bronchitis.]—Ed. 380 BRONCHITIS. and constantly acted upon by Cullen, Fordyce, and others, many years ago, and it surprises me greatly to hear this practice attributed to Italian and French physicians. Digitalis is of little use, unless given in considerably larger doses than are generally recommended; but it is a dangerous remedy when the air passages are much loaded. Col- chicum has been highly recommended in this disease by a friend, who states that its effect on the pulse and the other symptoms, are sometimes quite remarkable. Emetics are very serviceable in the first stage, and are absolutely necessary in the last, in order to clear the air-passages when the cough fails to do so; and are more particularly serviceable in childhood and infancy. Purgatives were at one time thought highly injurious in all inflam- matory affections of the lungs, but upon erroneous pathological views. Expectorants and diaphoretics are more injurious than beneficial, except perhaps in chronic affections; and I have often had to regret the loss of much valuable time by trusting to their action. Opiates are perhaps more frequently injudiciously administered in inflammatory affections of the lungs, than in any other class of dis- eases. They are sometimes exceedingly serviceable, but in the great proportion of cases they are injurious, and in some the cause of death. These observations apply more particularly to the disease under con- sideration. Nothing will be found more detrimental than opiates, in the last part of the second, and during the whole of the third stage of bronchitis, when the patient's life depends upon the cough and the expectoration; and many an individual has perished under such cir- cumstances, in consequence of a three hours' sleep. But they are sometimes useful, in the first stage, after the violence of the disease has been reduced by the lancet; they subdue irritation, the continu- ance of which would perhaps lead to a relapse. In the last stage also, they are serviceable when there is little or no secretion in the air-pas- sages, and when there is considerable irritation and a violent cough, which, if not mitigated, keep the patient from sleep, and wear him out. Counter-irritation is another powerful remedy in pulmonary inflam- mations; but all authors agree in condemning the too early applica- tion of blisters, which, in truth, ought to be employed oftener as a measure of safety, than of necessity. In acute cases, we cannot wait for the counter-irritation produced by antimony ointment, a blister should therefore be applied. • Attention, during the whole period of the disease, should be paid to the temperature of the extremities; and a warm bath has some- times excellent effects in removing irritation, and promoting the corn- first of the patient. BRONCHITIS. 381 The regimen should be strictly antiphlogistic; but stimulants are occasionally very serviceable in the last stage. The patient is some- times so weak and languid, that he cannot make any voluntary efforts to cough, upon which, perhaps, his life depends. In such a case, a stimulant frequently repeated, occasionally snatches an individual from the grave. It is difficult, however, to account for the stimulating treat- ment practised by Laennec, who, in recommending the use of the spirituous preparations, such as warm wine, burnt brandy, and punch, says—"This plan is unquestionably eminently successful in a vast number of cases. By it we frequently observe a cold which seemed to threaten great severity, cured all at once in the course of a single night." (Page 70.) But he observes in the subsequent page, that this plan is most successful in the very onset of catarrh; and that it is much less so after the supervention of the loose expectoration. Whether this be owing to difference of climate or constitution, it is difficult to determine; but that the disease of which I have been treat- ing, demands very different means on this side of the channel, I need not waste time to prove. In the treatment of acute and sub-acute pulmonary inflammation, it is necessary to keep the patient quiet in bed—every exertion is to be avoided; the exercise of the voice is also injurious; and during re- covery, it is essential to attend to the diet and clothing; the bowels are still to be regulated; and bitters are sometimes serviceable. In severe cases 1 hold it to be of advantage to persevere, for several weeks, in keeping up an eruption on the surface of the chest, by the application of tartrate of antimony ointment, or the frequent applica- tion of mustard plasters, or stimulating embrocations. Change of air, however serviceable it may be in some chronic cases, is often very detrimental in those now under consideration, unless it be from the smoky air of London to the country; and even then it is always doubt- ful whether the patient is to be benefited or injured by the change. Treatment of Chronic Bronchitis.—In the treatment of this form of the disease, we must ever keep in view, that patients are in danger of sudden attacks of acute inflammation, which may terminate fatally; or the substance of the lungs may become affected, from the diseased action spreading by contiguity; lastly, oedema of the lungs may take place, which is a common consequence of this affection. General bleeding is rarely necessary, except under the following circumstances, viz. the occurrence of acute inflammation, sudden con- gestion of the lungs; or dropsy depending on bronchitis. Counter- stimulants are almost as rarely necessary as general bleeding. The 382 BRONCHITIS. frequent exhibition of emetics cannot be too highly extolled; they appear to be most serviceable at night, immediately before the usual hour of rest, and in the morning, particularly after a tolerable long sleep: their modus operandi has been already explained. Constant attention to the bowels is of the greatest utility; and the occasional use of the warm bath is serviceable when the skin is dry and harsh. Expectorants appear to be sometimes serviceable, and the best is squills. I have seen expectorants used for a considerable time without any benefit, but after the application of a blister, or the use of the inhaler, the discharge has become free and easy. Of all the remedies hitherto recommended for the cure of chronic bronchitis, the best is long-continued counter-irritation by a scuccession of blisters, and par- ticularly by the application of antimony ointment. [When the disease is confined to one lung, and especially to a part only of one lung, the most effectual counter-irritant is an issue formed by the paste of caustic potash and soap.] The balsams have been strongly recommended for their peculiar efficacy in inflammation of the mucous membrane, more especially that of the lungs. Dr. Armstrong has spoken very favourably of them in his work on Scarlatina, &c. but I have no doubt, subsequent experience modified his opinions upon this subject. I have tried the copaiva in many cases in practice, without being able to discover its efficacy.* Tar vapour has been recommended as a sovereign remedy in phthisis, and there can be no doubt it has been beneficial; but the cases in which service may be expected, are those of uncomplicated chronic bronchitis. 1 think good effects have frequently been pro- duced by the tinctura lyttx, but exhibited in doses two or three times greater than those commonly used. [The preparations of iodine should not be overlooked. In dry ca- tarrh they sometimes speedily excite the mucous secretion, to the great relief of the patient. But iodine, should not be administered until the active inflammatory symptoms are arrested.] If change of air be had recourse to, a warm situation should be chosen with a dry sandy soil; patients should avoid exposing them- selves in cold damp weather, particularly in this country, when the wind blows from the east. Warm clothing is highly necessary; but it is important that medical men should prevent the patient from being too much loaded; and the best way to accomplish this is, by [* I have had much reason to bo gratified with the effects of the balsams, es- pecially tolu and copaiva, in bronchial inflammation. See Pr. 21, 23, and 24.]—Ed. inflammation op the larynx. 383 recommending a leathern jacket and drawers, and to forbid a great coat, particularly if he be allowed to take walking exercise. I must refer the reader to Dr. Forbes's translation of Laennec's work, for much valuable information on the subject of bronchial disease, and to the notes of the accomplished and experienced translator also, who has conferred a great boon upon British practitioners. INFLAMMATION OF THE LARYNX. This disease has a very close analogy to croup, which, indeed, sel- dom exists without extending to the membrane lining the larynx; but as the inflammation is sometimes entirely confined to the latter organ, it is necessary to give a separate description of each disease. Inflammation of the larynx is a common cause of death in small- pox and scarlatina, and it sometimes follows measles. When this disease occurs in the acute form, it is known by a painful sense of constriction in the throat, which is increased by pressing the larynx; speaking aggravates the pain, as does swallowing; the voice is hoarse; the breathing soon becomes laborious and shrill during the act of in- spiration; there is considerable heat of skin, thirst, rapid pulse, and great anxiety On looking into the throat, the fauces frequently look swollen and turgid, and of a dark red colour, or coated with lymph; but this affection of the throat is not peculiar to laryngitis, as the in- flammation may be entirely confined to the larynx. In some cases, the epiglottis is involved, which renders the motion of the tongue painful. The patient is constantly hawking, in order to clear the air- passages, and occasionally spits up a small quantity of thick tenacious mucus. As the disease advances, the face becomes swollen and turgid, it has frequently a livid appearance, and life is quickly destroyed by suffocation. Convulsions occasionally precede death. This disease sometimes runs its course in from thirty-six to forty-eight hours. A chronic form of inflammation of the larynx, although described by some as being of more common occurrence than the acute, is, I apprehend, less frequently met with; the mistake having arisen from its being confounded with the disease described by Bayle, under the name of oedema glottidis. That chronic inflammation, however, does take place, we have very good proof, from the ulcerations which are sometimes found in the larynx, and also round the glottis, which even destroys portions of the cartilages. In the chronic disease, par- ticularly when attended with ulceration, there is pain ascribed to the 384 croup. part affected, great difficulty and pain in swallowing, hoarse voice and dyspnoea; the patient passes distressing feverish nights, and expecto- rates a scanty sanious-looking matter, which has occasionally an of- fensive odour. This form of the disease sometimes accompanies phthisis pulmonalis; whether it does so or not, the patient becomes emaciated, and dies with the usual symptoms of hectic fever. On dissection, in the acute disease, the mucous membrane is found vascular, thickened, and rough from minute ulcerations, or it is covered with a thick exudation of lymph. [In other instances the ulcers are large, dark coloured, and even in a state of sphacelus. I have always observed that when the patient's voice has been reduced to a whisper, the vocal ligaments have been more or less involved in the ulceration. It may here be observed, that chronic inflammation and ulceration are more frequent in the trachea than in the larynx, producing a fear- ful destruction of parts. 1 have seen the tracheal cartilages eaten through by ulceration; and cases are recorded in which the purulent matter formed a pouch-like abscess in the integuments of the neck.] With respect to the treatment, as it is similar to that recommended in croup, I shall consider them together, after describing the latter disease. CROUP. This disease is of frequent occurrence among children residing in damp bleak situations on the sea coast; it consists of an inflammation of the lining membrane of the trachea, and is often connected with bronchitis and laryngitis, the one running into the other, so much so, that they frequently cannot be distinguished. It is scarcely a hundred years since this disease was first recognized, but the first good descrip- tion was given by the late Dr. Home. It is rather curious that croup is a disease almost peculiar to infancy and childhood, while inflamma- tion of the larynx and bronchial tubes occurs at all ages. Although there are some instances of croup affecting adults,* yet it is rare to see it after twelve years of age. One attack predisposes to another; but as age advances, this susceptibility goes off. It is more frequently met * It would appear that General Washington, the liberator of America, and Jose- phine Bonaparte, both died of this affection. The last fact is stated by Bretonneau, (at page 65.) on the authority of Beclard, who discovered the disease when em- ployed in embalming the body. CROUP. 385 with on the sea-coast than in inland districts, and in the neighbour- hood of wet marshy lands than in dry situations; thus it appears to be more frequent in Leith than in Edinburgh, notwithstanding the high and exposed situation of the latter. Dr. James Hamilton, jun. has stated, but perhaps precipitately, that croup is a common disease in certain parts of Edinburgh. Above three thousand people have been attended annually by my pupils for several years past, and out of more than eighteen thousand patients we have not had above twelve cases of croup; but I have frequently been asked to attend dissections of children, who were supposed to have died of croup, which proved upon examination to be bronchitis. Croup has been divided into three species, viz. the acute, chronic, and spasmodic. Under this last head, I shall take an opportunity of no- ticing the affection already mentioned, as first described by Bayle in the year 1819. Phenomena.—It usually commences like a catarrh, the symptoms being more or less severe, with some degree of fever, preceded by chilliness; the voice soon becomes hoarse; febrile symptoms increase; and in a day or two, the breathing becomes more and more impeded, particularly during inspiration; at last the respiration becomes stridu- lus, and the voice shrill; a harsh, dry cough exists from the begin- ning, and when there is any expectoration, it has more or less of a muco-purulent appearance; sometimes small masses of lymph are dis- charged, which occasionally resemble portions of false membrane. As the disease advances, the expression of countenance becomes more anxious; the lips and cheeks have a swollen, livid appearance, alter- nating perhaps with a deadly paleness. The pulse is frequent and small, and occasionally intermits. There is prostration of strength, and restlessness; although the surface of the body be, generally speak- ing, hot, the extremities are frequently cold; at last, the body is covered with a cold, clammy sweat, and the child ctyes of suffocation. On looking into the throat, the fauces are sometimes found inflamed and swollen; but this is not a necessary part of the disease; it merely shows that the inflammation is extensive. Many cases of croup, however, which I have seen, appear to have been produced by the extension of inflammation from the throat into the air-passages. This was the case in the disease described by M. Bretonneau, and to which he gave the name of diphth6rite.* The course of the disease is various; sometimes children are cut off early from asphyxia, but in * Traite de la Diphtherite, par P. Bretonneau, 1826 Vol. I.—49 386 CROUP. general it lasts from two to four days. In chronic affections of the trachea, the symptoms are less violent and urgent, but having, upon the whole, pretty much the same character, viz. dyspnoea, shrill voice, and stridulous breathing. This is probably the affection that Dr. Warren has called " bronchial polypus," and which he has described in the 1st volume of the Transactions of the College of Physicians. Causes.—There can be no doubt that cold and moisture produce the disease, and that sometimes, from peculiar circumstances, a great many cases have occurred in the same district. The most remarkable epi- demic appears to be that which took place at Tours some years ago, and which is described by M. Bretonneau, during which one hundred and fifty individuals died. It affected adults as well as children, and was particularly severe in a French legion quartered in the district. This author supposes it to be contagious, which, from the facts he has detailed, is very probable, although there are a great many difficulties yet to be solved before we can altogether admit this point. It some- times succeeds to bronchitis, and also to severe inflammation of the fauces. Appearances on dissection.—On opening the trachea, false mem- brane is found lining the organ in various states; sometimes it is soft and diffluent; sometimes partial; at others extending beyond the bifurcation. Sometimes it is found of very considerable thickness and firmness, of a tubular form, corresponding exactly with the canal which it covers, and extending an inch or two into the bronchi; on some occasions, the first divisions of the tubes are as completely lined as the trachea. Frequently the larynx is similarly affected, but I have never seen a complete tube in this situation. On some occasions, bronchitis co-exists in one lung, or in both, which must always be kept in view, when considering the probability of affording relief by the operation of bronchotomy. I have seen the lungs inflamed in various degrees, and almost always considerable portions are in a state of engorgement, owing perhaps to the mechanical impediment to re- spiration. In M. Bretonneau's numerous dissections, false membrane was found extending from the tonsils down the air-passages, and some- times even into the oesophagus. Pathological remarks.—Since the publication of Dr. Cheyne's beautiful illustrations of the croup, no doubt has existed that the false membrane is the product of severe inflammatory action of the mucous surface. A great deal too much has been attributed to spasm in this disease. CROUP. 387 Cullen, for instance, assigns more danger to spasmodic action, than to the exudation of lymph. In the 327th paragraph, he says: "The pe- culiar and troublesome circumstance of the disease, seems to consist in a spasm of the muscles of the glottis, which, by inducing a suffoca- tion, prevents the common consequences of inflammation:" and again, in the 329th, "When the disease ends fatally, it is by a suffocation, seemingly as we have said, depending upon a spasm affecting the glottis; but sometimes, probably, depending upon the quantity of matter filling the bronchiae." At the same time, he attributed the febrile symptoms to a corresponding spasm on the surface; in fact, he was fond of riding his spasmodic hobby, and being unacquainted with pathological investigations, his great mind was frequently turned out of the proper path of inquiry. Spasm may certainly exist in this disease; but there is sufficient reason to account for the symptoms without having recourse to spasm as a cause. We have at first slight difficulty of breathing, from the increased vascularity and distension of the vessels of the mucous membrane producing swelling, and consequently some diminution in the calibre of the air-tube; subsequently, from a greater or less de- gree of congestion of the lungs; and lastly, from the exudation. Death is sometimes produced by asphyxia early in the disease, by congestion of the lungs, and by the inflammation being peculiarly severe at the rima of the glottis, occasioning such a degree of swelling as to prevent inspiration, and children often die during the act of crowing. Treatment*—This is a disease of all others which requires prompt- ness of decision and activity in practice; for if the false membrane be allowed to form, not above one case in the hundred will be saved. The worst cases are those in which a sore throat has been neglected, and the inflammation has spread into the windpipe; or those in which patients have laboured under bronchitic symptoms for a week, or per- haps more, before the disease has affected the trachea and larynx, under which circumstances a recovery is rather to be considered as an escape, than as an event to be expected. Very opposite opinions exist respecting the treatment; some trust, perhaps too much, to bleeding and blistering, to the neglect of other means; and there are others who assert that bleeding is injurious. I shall first state the practice which I have found to be successful, and afterwards that which has been recommended by others. If consulted early, there can be no doubt of the propriety, nay, ' The same observations are equally applicable to inflammation of the larynx. 388 croup. necessity of drawing blood; if by opening a vein, so much the better, because we can thereby make an instantaneous impression upon the disease, and upon the system, by diminishing the quantity of blood, altering the determination, and unloading the lungs. However young the child, if above eighteen months or two years old, I would recom- mend this practice from experience; but only when the child has been previously healthy, and we are satisfied that there is no considerable effusion into the ramifications of the bronchi, and that the false mem- brane is not already formed in the trachea; otherwise, death will fre- quently be the consequence. This happened in the case related in the 18th observation of Bretonneau's work; the patient was bled on the sixth day of a severe disease, and died the same night. Among other ap- pearances found in the dissection of this case, the following are described at page 160.—" The false membrane lined the larynx, the trachea, and extended deep into the air-passages, even to the fourth subdivision of the bronchi of the right side, and the last ramifications on the left. '* Leeches are to be applied in numbers corresponding to the age, strength of constitution of the patient, and period of the disease; and should be placed along the course of the wind-pipe, or top of the sternum; they should be repeated according to circumstances. But it can be of no use to draw blood even in this manner, if a sufficient number of leeches be not used, and re-applied at sufficiently short in- tervals, or if not employed till the false membrane is already formed. In the case which forms Bretonneau's 17th observation, detailed at page 155, it will be found that a child of twenty-seven months old was seized on the 4th December with a slight cold, and altered tone of voice. During the 5th and 6th, it became worse, and on the 7th, we are told that three leeches were applied to the neck, and a little ipecacuan was prescribed, which was continued on the 8th and 9th without the leeches; the child died on the 12th. It is no wonder, then, that this author should condemn depletion, this being the way in which it was employed. If general blood-letting be used, one operation ought to be sufficient, and we must subsequently trust to the application of leeches. Emetics are to be administered, more especially at the beginning of the disease, and when it is complicated with bronchitic effusion. In the commencement, the best emetics are the antimonial, prepared by dissolving two grains of the tartrate of antimony in two ounces of water, a tea-spoonful of which is to be given every five or ten minutes, till the full effect is produced. In many cases it is difficult to produce vomiting; but by giving the antimony, we insure its counter-stimu- croup. 389 lant effects, whether vomiting be produced or not. Brisk purgatives are also necessary, until the bowels are freely opened. During the whole course of the disease, the warm bath used occasionally through the day, will be found serviceable. The effect of blisters is often very decisive in the first stage, after bleeding and leeching have diminished the violence of the disease; but it is needless to torture children after the false membrane is formed. Children can rarely be made to inhale hot vapour; if they can, it will be found very serviceable. We are informed by Dr. Mason Good, that two physicians of St. Petersburgh, Drs. Harden and Miller, had ventured upon cold effusion after every other remedy had failed, and the practice was attended with success; but no one who understands the pathology of this dis- ease, and has seen the appearances on dissection, will believe that the false membrane could be removed by such means. I have a very high opinion of the action of calomel in this disease, if employed early, and not trusted to entirely, to the neglect of gene- ral and local bleeding. The more rapidly the system is affected the better; and it should be given in doses of two, three, and four grains, so that from two to three scruples are taken during the first twenty- four hours. If the calomel produce hypercatharsis, it is to be discon- tinued, and mercurial ointment is to be rubbed in on various parts of the body. The mercurial treatment should not, however, be too long persisted in; if it is to have any effect, it should be seen within the first thirty or thirty-six hours. It is impossible to say in what man- ner the calomel acts.* Mason Good says, " it not only acts by excit- ing a salutary revulsion or counter-action, but breaks down the thicker parts of the blood, from which the membranous secretion is princi- pally furnished/" Page 427. Dr. James Hamilton, jun. was once a mercurial champion of the highest order; he used calomel in very large quantities; but he has now changed his opinion, and considers it in the light of a poison in almost every other disease but syphilis. Is there another individual in the British empire who, having cured forty-six out of fifty cases of such a dreadful disease as croup, by means of the action of calomel, which Dr. Hamilton alleges he has done,t would not feel justified in recommending others to follow the same treatment? But this useful remedy has since been cast in the back-ground, and he has attempted to prove, " that the action of mer- [* I suppose it to act by exciting copious secretion in the mucous glands and cryptse, which are so abundantly distributed throughout the lining membrane of the respiratory tubes.]—Ed. f " On the Use and Abuse of Mercury," &c. page 206. 390 CROUP. cury tends, by exciting inflammation and effusion, to produce thick- ening of various membranes, particularly of the pleura."* Bronchotomy has been frequently recommended in croup, and oc- casionally successfully practised. There are cases in which it ought to be performed, because there is a possible chance of success; and there are others in which such a step will only tend to bring surgery into disgrace. If the disease be confined to the larynx and upper part of the trachea, we ought not to hesitate when suffocation is threatened; but if the membrane extend into the bronchial tubes, or be complica- ted with extensive bronchitic inflammation and effusion into both lungs, it will be improper. It appears to me that bronchotomy should be had recourse to under the three following circumstances only:—In inflammation of the larynx, threatening suffocation;—when foreign bodies have accidentally found their way into the larynx;—and in the peculiar affection of the epiglottis, larynx, and rima glottidis, which was first minutely described by Bayle. When performing this operation in a case of croup, it should be always kept in view, that if the disease be far advanced, the false membrane has a tubular form; in fact, it has taken the shape of the canal, from the surface of which it is very easily separated; so that when the incision is made through the cartilages, the membrane may collapse from the pressure of the atmosphere, and produce instant death. Before quitting this subject, I may mention that Bretonneau, in the epidemic which he described, trusted at last entirely to the ac- tion of mercury, and the local application to the inflamed tonsils, of pure muriatic acid; and he assures us that the practice was attended with great success. With regard to calomel, he says, (at page 94,) that its good effects were perceived in a few hours after the adminis- tration of the first doses. But after a careful perusal of the work, and the result of the practice, I see no reason to alter the opinions already expressed. Chronic inflammation of the trachea requires the frequent applica- tion of leeches, with blisters alternately; inhaling the vapour of warm water,as well as breathing the vapour of tar, together with an occasional emetic; the steady use of laxatives; warm clothing,and farinaceous diet. The disease which is described by Bayle, and to which I have seve- ral times alluded, is an oedematous affection of the larynx, glottis, and epiglottis. I conceive, however, that it is often owing to the swelling produced in the first stage of acute inflammation of the mucous mem- * " On the Use and Abuse of Mercury," &c. page 219. CROUP. 391 branc also, when it is swollen and dry; and also to chronic inflamma- tion, which is not attended by oedema. It is sometimes produced by sudden congestion of the vessels of the mucous membrane, which had previously been in a state of irritation, as 1 shall attempt to show, when treating of the pathology of hooping-cough. It appears to me, that this is the disease which sometimes goes by the name of "spasmodic croup." The same pathology likewise serves to account for the phenomena of the affection, which is commonly known by the appellation of " crowing disease." It is probable, that this is the true pathology of the disease de- scribed long ago by Miller, and afterwards noticed by Parr and others, under the denomination of "spasmodic asthma of children." It is supposed that croup is a disease consisting of a combination of inflammation and spasm; but, that spasmodic croup consists entirely of spasm. Occasionally, children die after giving a single crow, and I had once an opportunity of seeing a man of 40 years of age die in a few hours from the first attack. Upon minute inquiry, it will be found, however, that individuals cut off in this sudden manner, have for some days or weeks laboured under what is called a common cold. I am inclined to believe that this disease may be produced by cere- bral irritation, causing some morbid action in the nerves that supply the muscles of the throat, and which, by producing a convulsive spasm, occasions the contraction of the larynx, so as to produce the following phenomena. Symptoms.—Children are generally seized in the evening, or during night, with a sense of coldness over the whole surface, and laborious breathing. During inspiration, a long shrill sound is pro- duced, alternately with coughing, and occasionally weeping, when the voice is observed to be hoarse and croaking. There is a sense of constriction in the throat, an expression of great anxiety in the coun- tenance, with lividity of the cheeks and lips. These phenomena are produced by the application of cold, and even by cold feet; they frequently occur during dentition. The bowels are almost always found to be in a neglected state. The disease is rarely fatal. ^ On dissection, the lungs will befround in general loaded with dark- coloured blood, so much so, as to«ve lost a great deal of their natu- ral colour and buoyancy. At one time, I was disposed to regard this condition of the lungs as the disease, till a fatal case occurred, at the dissection of which I had the able assistance of my colleague, Mr. Syme, who displayed the state of the mucous membrane of the larynx 392 CROUP. in the most satisfactory manner, and drew my attention to the me- moir written by Bayle. The following is a history of the case. Edward Currie, aet. 40, a labourer.—Up to the period of the great fires in Edinburgh, which took place in November, 1824, he had always been a healthy, stout man. During his attendance in working the engines, and in carrying water, he was exposed to cold and wet, and was subsequently affected with what he called a severe cold and sore throat, attended by occasional headaches; but having a large family, and being of industrious habits, he continued to work at his daily labour. On the 2d day of January following, he became worse, and was unable to go out, but sat at the fire-side almost the whole of the day, complaining of chilliness, sore throat, and tightness about his chest. After passing a restless night, he sent to my dispensary for assistance on Monday. At 5 o'clock in the evening, he had severe rigors and difficulty of breathing, and at half past 6, was visited by one of my pupils, Mr. Marshall, whose name is associated with many other interesting cases, and from whom I received the following re- port:—" On seeing him I believed he had caught a cold; he com- plained of sore throat, and evinced some uneasiness in swallowing, but there was no appearance of inflammation of the fauces, nor pain on pressing the wind-pipe. The rigors were still severe, the pulse strong, beating about 70 in the minute, and there was a sense of con- striction in the chest. He was bled to the amount of 18 oz. during which the rigors ceased, but afterwards returned." Mr. Marshall thought his patient was in no danger, and that the symptoms would soon give way to the remedies he had prescribed; but in about an hour after he took his leave, the dyspnoea became much worse, attended with severe rigors. Mr. Davidson, a respecta- ble surgeon in the neighbourhood, was immediately sent for, who found the man in such a dangerous state, that he wished me to be present before any further step was taken; but soon the symptoms became so much more urgent, that he could wait no longer, and he opened a vein in the arm: the blood was flowing on my arrival. About 18 oz. were abstracted with very little or no relief: although a large orifice was made, the blood did not flow in a stream, and it was very dark-coloured and thick, lit coagulated very imperfectly, yielded no serum, and had everAppearance of what is commonly called " dissolved putrid blood." The state of the respiration some- times resembled that which is heard in croup, after the formation of the false membrane; at others, that of hooping-cough, during the paroxysm; indeed, the similarity was so great, that 1 heard a number croup. 393 of women discussing the point. It was ascertained that he experi- enced the greatest difficulty in breathing during the act of inspiration, when he made the shrill crowing noise. There was cough. He spoke distinctly after the bleeding, which he could not do before, but it was in a low voice, and the exercise seemed to cost him a consider- able effort; he said, " I feel rather better." His face was pale and anxious, and I was told that it had been so for several hours, pulse rapid and feeble. Upon being subsequently asked if he had any pain, and where it was situated, he replied by placing his hand upon the thorax, and nodding. During the momentary absence of Mr. David- son and myself in an adjoining apartment, the patient felt a desire to make water, and actually got out of bed unassisted, and lifted the chamber-pot. Upon our return, he was cautioned to lie down, and on no account to make such an exertion again; but he persisted, de- claring he felt somewhat better, and in a moment afterwards he was dead. The body was opened 36 hours after death. The following were the appearances observed. Right lung attached, throughout its whole extent, by old adhesions to the pleura costalis, left lung free. The lungs and trachea were then carefully dissected out, including the root of the tongue, and minutely examined. The lungs were of a very dark colour, heavy, and congested every where with dark-coloured blood; and although there was no hepatization, yet two-thirds of these organs, when separated into small pieces, sank in water, a little below the surface; this was proved not to depend on alteration of structure, for by washing they were restored to their natural colour and buoy- ancy. The mucous membrane every where in the larynx, trachea, and bronchial tubes, was of a dark red colour, and coated with red- dish mucus; but the bronchial tubes were not gorged with it, as seen in the lungs of those who die of bronchitis; the larynx was found so much ossified, that after being slit open, it could not be separated to any extent; the mucous membrane at this part was found so much swollen, as to leave the smallest possible passage for the transmission of air at the superior, but particularly the inferior aperture; the epi- glottis was much swollen, erect, stiff, and of a red colour. Treatment.—This affection in children frequently terminates after copious perspiration, so that nurses liave been led to put them as soon as possible into a hot bath, which is in general efficacious, and it is the first thing that ought to be done. An emetic ought also to be given, and if these means fail, a vein should be opened, and a mo- derate quantity of blood abstracted, or leeches applied about the Vol. I.-—50 394 HOOPING-COUGH. larynx. This is the case of all others for bronchotomy, and I confess that it is probable the life of Currie might have been saved, if the operation had been had recourse to. M. Thuilier has recommended compression from time to time of the oedematous epiglottis, which will not be easily effected; and if it could, little service would follow, as it is the condition of the membrane at the rima of the glottis, which occasions the danger. Bayle proposed the introduction of a sound into the trachea, failing which, bronchotomy. Lisfranc suggested that incisions should be made into the oedematous parts, to facilitate the discharge. HOOPING-COUGH. This disease is also known by the, appellations chin-cough, kink- cough, &c. and it is probable that it is not a disease of such recent origin as has hitherto been imagined. Gardien very sensibly states, that if it has not been described in France until the year 1414, it is because it has always been confounded with other species of coughs. Indeed, some pretend that it was known to Hippocrates, while others assert that it was imported in more recent times from the East. It is not of much consequence how this matter really stands, because the most perfect knowledge as to its true origin, would not enable us to treat the disease more successfully. Hooping-cough is a Disease of Childhood, although I have seen many instances in adult age. He- berden says that he has seen it in a woman threescore and ten, and in a man of eighty years of age. It may be said to occur once only in a lifetime, but several cases have fallen under my notice of second- ary attacks. Dr. Rosenstein states, in his work on the Diseases of Chil- dren, &c. that in Sweden, in the course of sixteen years from 1749, forty-three thousand three hundred and ninety-three children died of the hooping-cough, which gives an average of 2712 per annum; but in the year 1755, five thousand eight hundred and thirty-two children died of this distemper. In general, the annual mortality amounted to from seventeen hundred to two thousand in that kingdom. Accord- ing to Dr. Watt, the deaths from hooping-cough in Glasgow have been pretty nearly 5i per cent, of the vs»hole deaths in that city; the greater number in any one year took place in 1S09, when they amounted to Hi per cent.; and he concludes, that next to the small-pox formerly, and measles now, chin-cough is the most fatal disease to which chil- dren are liable. He gives a table, which appears to prove, that in young HOOPING-COUGH. 395 children there is more danger than in those further advanced in life; which does not altogether accord with my experience.* Phenomena.—In the first stage of hooping-cough the disease is almost always confounded with a common slight catarrh; the duration of this stage varies very much; in general however it extends from ten to twenty days. There is a dry cough, occasional sense of constriction in the chest, and a feeling of weight in the head. The eyes are sometimes a little swollen and red, with frequent sneezing, and in- voluntary tears; in many cases there is little or no fever except during the night; the bowels are generally out of order. We sometimes suspect the disease to be hooping-cough, beacuse it is epidemic at the time, or in consequence of the convulsive appearance of the paroxysm of coughing. At last, however, the cough assumes a peculiar cha- racter; when this takes place, the disease is said to be in the second stage. It is characterized by an inspiration which is long and sono- rous, producing a peculiar shrill noise, which is termed, in common language, the hoop or kink, to which succeeds an expiration which is broken by frequent fits of coughing. No one who has seen the disease, when fully formed,, can mistake it. When the cough commences, in slight cases, the features become a little swollen, the face red, the eyes suffused with tears; the cough, which is frequently interrupted by a long inspiration, is hoarse; the paroxysm ceasing with an expectora- tion more or less copious, frequently assisted by the act of vomiting, which discharges the contents of the stomach. As soon as this is accomplished, children are commonly able to return to their usual amusements, and appear to suffer little or nothing, until towards the period of the next paroxysm. The appetite is in general good. The expectoration is at first slight, scanty, and viscid; but if the disease go on in a favourable manner, the discharge becomes more copious, and less tenacious. Young children scarcely ever spit out the expecto- ration, unless during the act of vomiting; it is generally swallowed as soon as discharged from the air-passages. The patient is, in general, warned of the approach of the paroxysm, by a greater or less degree of chilliness on the surface, and a tickling in the throat, immediately succeeded by a sense of tightness both in the larynx and chest, and a dread of suffocation, which induces him to fly to his nurse, or to lay hold of any thing within reach, for support during the fit. Others seem to derive relief from lying on all-fours on * It affords me great pleasure to refer the reader to Dr. Watt's work on hoop- ing-cough, as the best which has ever been published; and to that of the late Dr. Marcus of Bamberg, who died the day after he sent his preface to the press. 396 HOOPING-COUGH. the ground, and when the discharge has taken place, they jump up and run about. In more severe cases, the sense of suffocation is dreadful; the respi- ration is much more impeded; the cough more intense and protracted; the features more swollen, and of a livid colour; the eyes seem ready to start out of their sockets; the eyelids are much swollen, and the cheeks perhaps bathed in tears; till at last expectoration takes place, when the children pant for breath, and are unable to return to their play for a considerable time. The skin is above the natural tempera- ture, particularly at night; complaint is made of headache; the appe- tite is bad, the bowels are much disordered, and flatulent distension aggravates the patient's sufferings. The straining which takes place during the paroxysm is sometimes so severe, as to produce the involuntary discharge of feces and urine. It is no uncommon thing for a small blood-vessel to give away in the conjunctiva, producing ecchymosis; haemoptysis itself occasionally takes place, but this is rare in comparison to epistaxis, which is very frequent, and, when it takes place in plethoric children, is considered a very fortunate occurrence. In the worst forms of the disease, fever is constantly present, and the breathing is always more or less impeded, which shows that some mischief is going on internally. Fits of temporary asphyxia are fre- quent; they are very often mistaken for convulsions, and by them children are sometimes instantly cut off. Indeed, children have been known to die suddenly during a paroxysm, asphyxiated, whose cases were previously slight, and not attended with fever. In some in- stances, convulsions occur, and carry off the patient. Many of the severe cases met with in practice, are those in which this disease is engrafted, as it were, on bronchitis; or succeeds to small-pox or measles. Causes.—Hooping-cough is rarely sporadic; it generally prevails as an epidemic. Some assert that it is unquestionably contagious, while others allege that it is not so. Some suppose that it is a disease produced by a miasm of a specific nature. Appearances on dissection.—I have had between forty and fifty opportunities of examining the bodies of those who died of this dis- ease.* In one severe epidemic, we had upwards of two hundred * It may be mentioned as a remarkable fact, evincing the improved state of so- ciety, and the advantages of education, in removing prejudices and destroying su- perstition, that in Edinburgh we are rarely prevented from examining a body after HOOPING-COUGH. 397 cases at the dispensary, out of which there were thirty-two deaths. The appearances found on dissection were very uniform, according to the period of the disease at which death took place. I have seen two dissections of children who died asphyxiated, during the paroxysm, and in these the lungs were found to be gorged with blood; the whole lung, when put into water, showing far less buoyancy than natural, and large portions when cut off, were found to sink to the bottom of the vessel. But it was proved that the increase of gravity was not owing to alteration in the texture of the organ, which resumed the natural colour, appearance, and buoyancy, when deprived of the blood by washing. The right side of the heart, and the large vessels near it, were distended with dark blood. The mucous membrane of the air-passages every where presented a dark red appearance, seemingly thickened, the tubes containing more or less mucus tinged with blood. The brain was not examined. In ordinary cases, when death takes place during the second, third, or fourth week, the following is a sketch of the appearances. In the head, marks of vascularity and of venous turgescence, and sometimes also efiusion of serum between the membranes, and in the ventricles; but these were far from being invariable appearances. In some few cases, there was great vascularity, and some effusion at the base of the brain, more particularly at the origin of the nerves, but not to a greater extent than has been frequently remarked in bronchitis, and other diseases in which there was no tendency to spasmodic cough, or to spasm of any kind. In one case, which was accompanied by violent and intractable convulsions, with considerable rigidity of the superior extremities, the substance of the brain had a rosy tint; on making sections, large drops of blood quickly exuded from numer- ous points on the cut surfaces. On exposing the lateral ventricles, the left corpus striatum and thalamus were observed to be enlarged, particularly the former; in so much, that in measuring the depth of the brain on each side, it was discovered to be nearly half an inch deeper on the diseased side than the other; when cut into, it was found to be rather harder than the corresponding parts on the oppo- site side. The child had previously enjoyed a good state of health, and even after death did not appear much emaciated. Traces of disease were invariably found in the thorax. On some death, if sufficient attention has been paid by a medical man during the course of the illness,—except by the low Irish population, who seem to have a more super- stitious regard for their dead on this side of the channel than in their own country. 398 HOOPING-COUGH. rare occasions, the lungs were somewhat collapsed; but in general they completely filled their respective cavities. In a few instances, the pleura costalis covered with lymph like an unctuous secretion. Once or twice the lungs adhered to the walls of the chest, by an in- termediate deposition of soft coagulating lymph. The anterior sur- face of the lungs, in almost all cases, presented spots of a whitish ap- pearance, as if coated over with lymph; but this was found, upon closer examination, to depend on emphysema, air being effused be- neath the pleura, from the rupture or enlargement of the air-cells; considerable portions were observed gorged with blood. Sometimes the substance of the lungs was in a state of oedema; and occasionally portions were observed inflamed. In persons who have not been cut off till the eighth or tenth week, tubercles in various states will frequently be observed; sometimes vesicular or crude, large and solitary, sometimes softened, and partly discharged by expectoration. On one or two occasions, I have seen one lung infiltrated with a soft caseous matter. The bronchial glands are found enlarged, if the patient do not die before the third or fourth week. The mucous membrane throughout the air-passages, has always displayed more or less vascularity, which increased towards the rami- fications, and the tubes were found filled with matter which had more or less resemblance to pus. In the trachea and larynx, this secretion is observed, but 1 have never seen them filled with it, like the bron- chial tubes. Sometimes flakes of coagulable lymph are observed, and ulcerations about the glottis, in the larynx and trachea, but more par- ticularly at the great bifurcation. In the abdomen, sometimes every structure appears to be in a healthy state; at others, the liver is found gorged with blood, some- times whiter, at others redder than natural. The mucous membrane of the stomach and bowels, has shown various red patches, and I have seen ulcerations in the colon, and enlargement of the mesenteric glands. Mr. Alcock, a scientific general practitioner in London, in one of the numbers of the Medical Intelligencer, states, that he " has re- peatedly ascertained by dissections of patients who have died of hooping-cough, that the larynx invariably exhibited signs of inflam- mation, often to so great an extent, as by its swelling to close mechan- ically the glottis; often the exudation of coagulable lymph near the larynx, the mucous membrane of the trachea and bronchiae much in- creased in vascularity, and the cavities of the latter filled with fluid HOOPING-COUGH. 399 more or less mixed with air, the appearance of the fluid varying from thin mucus to perfectly formed pus." This extract was presented to me by a friend one day after my lecture upon this subject, but I have never been able to procure the number of the periodical which con- tains the whole of the paper. I have thought it right, however, to give the extract, and to express the high respect I entertain for Mr. Alcock, from the accounts which have reached me at different times, of his zeal and indefatigable exertions for the improvement of pa- thology. These post-mortem appearances correspond with the dissections re- corded in Dr. Watt's Treatise. Pathology.—Until lately, the most uncertain opinions prevailed respecting the nature and seat of this disease. Some supposed it to be a nervous affection, and of a true spasmodic character. Chambon and others assert that it is a true catarrh of the stomach. Some re- present it to be a pure inflammation of the mucous membrane of the larynx, trachea, and bronchial tubes, to their termination in the air- cells. While there are others, like Gardien, who think that the dis- ease is partly situated in the lungs, but that the essence of it consists of a spasmodic affection of the glottis and diaphragm. In consulting the works of Willis, published in the year 1670, it will be seen that nothing was then known of the nature and seat of hooping-cough, and from the general want of success in treating it, this branch of practice fell into the hands of old women and quacks. According to the Brunonians, it is a disease of true debility. Some, indeed, conjoin it with typhus; while others allege, that it depends on inflammatory action in the brain. Rosenstein places the seat of hooping-cough in the nerves of the chest, and Hufeland agrees with him in that opinion. Autereith declares, he found the pneumo-gastric nerves inflamed. Breschet seems to support this opinion, but although this state of parts may have occurred on some occasions, it is denied as a more common cause by other authorities. Guersent has stated, that he opened a num- ber of bodies with a view to determine the fact, but he did not find the pneumo-gastric nerves diseased. No pathological information can be derived from Cullen's works, or even from Dr. Thomson's recent edition of them, respecting this, or any other disease; but according to his absurd nosological arrangement, it is evident he thought it to be of a nervous and spas- modic nature. Dr. Gregory, it would appear, gave up the investiga- tion of the nature and seat of the disease in despair, for he used to make the following statement in his lectures:—" I do not attempt the 100 HOOPING-COUGH. proximate cause, though 1 may mention I have no faith in the theory that was advanced some years ago, that the disease depended on the stomach; it is more probable that it is seated in the lungs." Yet he considered it to be of a spasmodic nature. The oldest opinion which can be traced, approaching to the true pathology of this interesting disease, is that which was advanced by the celebrated French writer Astruc, who states, (at page 142 of his Treatise on all the Diseases of Children,) that " this disease principally consists in inflammation of the superior part of the larynx and pha- rynx, and more particularly of the latter, which is sometimes ulcera- ted with the constriction of the glottis, as dissection proves. It appears to me, that investigators have been bewildered in endea- vouring to discover the first link in the chain of diseased action, and by the character of the cough, with regard to which, it should be re- collected, that a very slight degree of irritation in the larynx, and even about the glottis, will produce most violent convulsive fits of coughing. Dr. Watt says, that the cough is exactly what may be produced by any very violent irritation applied to the same parts, " of which, (says he,) I had a very striking proof some time ago. Two children had differed about their play; the one, who supposed himself ill used, to be revenged on the other, took a handful of saw- dust and endeavoured to thrust it into his mouth. He succeeded in his attempt. The other crying and struggling for relief, allowed a quantity of dust to be drawn into the windpipe. This gave great un- easiness, and after a short time excited violent convulsive fits of cough- ing, which exactly resembled those of the chin-cough. Even the hoop was very distinctly formed. At first he spat up nothing, after- wards thick mucus; at last the irritating cause being removed by the expectoration, the other symptoms disappeared. This was a very striking example of chin-cough being brought on artificially." I have sometimes seen the same effects in both old and young, from articles of food, and particularly small portions of sweet-meats, going the wrong way, as, it is termed, i. e. dropping into the larynx, or adhering somewhere about the margins of the glottis or epiglottis. I was once present at the dissection of a shoemaker, who died from extensive in- flammation of the throat and wind-pipe, and who had during the whole of his illness, of four days standing, violent convulsive fits of cough- ing, with a complete hoop. On examining the throat and air-passages, extensive inflammation was discovered, and a small piece of a hog's bristle was found sticking in the margin of the glottis. My opinion of the nature and seat of hooping-cough is as follows:— HOOPING-COUGH. 401 There is something peculiar in the disease, since almost no individual escapes contracting it once in his life time. I have no doubt that the nervous system is involved in the affection,—very seriously involved; but in the present state of our ignorance of the structure and functions of that system, the doctrine of spasm must be very cautiously received into the medical evidence of the case, more particularly as all the phe- nomena can be satisfactorily explained without its aid. The essence of the disease consists in irritation and inflammation of the mucous membranes of the body, but more particularly of the air-passages. This is proved by the pectoral or catarrhal symptoms, which are to be observed from the very first onset of the disease; by the increased secretion; and by the result of dissections. Some say that the dis- ease cannot be a consequence of inflammation, because there is no fe- brile excitement in the pulse in slight cases, and no increased heat of surface; but it is a fatal error to suppose that inflammation cannot exist without fever. In the majority of cases of hooping-cough, the inflammation, although extensive, is only slightly sub-acute, and there is consequently no heat of skin,—no increased velocity of the pulse, —no thirst; but when the inflammation runs a little higher, then we generally have these constitutional symptoms. It will be observed on perusing the description of this disease given by every author, that it begins with the common symptoms of catarrh, from which it cannot, during the first stage, be distinguished. The disease, when formed, comes on in paroxysms. I shall not stop to inquire whether these paroxysms are occasioned by a peculiar affection of the nervous system or not. The paroxysm commences with a sense of coldness on the surface, making an irregular determi- nation of blood, that takes place towards the lungs, which perhaps never will be satisfactorily explained. These organs become gorged with blood, and the air is consequently prevented from obtaining a free passage through the ramifications of the bronchi and air-cells; some degree of dyspnoea is produced, with tightness in the chest, and a sense of suffocation. All the powers of the constitution are brought into play to remove this congestion, violent coughing is excited,—all the voluntary muscles are called into excessive action, and a universal muscular commotion is produced, which tends to force the blood on its circulation,—a copious secretion takes place from the mucous membrane, probably throughout the whole extent of the air-passages; and the fit ceases when the mucus is discharged, which is sometimes promoted by the act of vomiting. Towards the close of the paroxysm, a determination of blood takes place to the skin, frequently producing Vol. I.—51 402 HOOPING-COUGH. copious perspiration, which is probably assisted, if not entirely pro- duced, by the violent muscular commotion into which the body is thrown. This is also perhaps another way by which the congestion of the lungs is removed. It is generally believed that the hoop is produced by spasm. It is not my business to attempt to disprove this allegation; but 1 have already shown that the hoop has been produced by extraneous bodies, which have found their way into the larynx, or have been lodged about the glottis. It has also been shown, that in pure inflammation of the mucous membrane of the larynx, before and after the effusion of coagulable lymph, the same sound has been heard; and also when the calibre of the larynx at the rima glottidis has been diminished by mere swelling of the mucous membrane, as well as by effusion, forming the disease which Bayle has described under the name of oedema glottidis. In all these cases, there is the long sonorous or shrill inspiration. Cullen says, (in the 1404th paragraph,) that "the peculiar sound is produced hy air rushing through the glottis with in- creased velocity." It is admitted that this is occasioned by the dimi- nution of the canal through which the air has to pass, and the only question to decide is the cause of this diminution. Cullen and others assert that this is owing to the spasmodic contraction of the muscles of the throat, which are connected with the larynx; while I presume, that it is generally owing to the other causes:—the fact is capable of explanation in both ways, but the decision will influence the treat- ment. In hooping-cough, we have decided evidence of congestion and inflammation of the air-passages; the larynx, and parts in the neighbourhood, principally suffer, and at the commencement of the paroxysm, when blood is accumulated in the lungs, the mucous mem- brane, I apprehend, becomes more swollen and the space at the rima of the glottis is diminished, so as to be almost closed. It is admitted that the difficulty which the air experiences in traversing this part, produces the phenomenon of the hoop, and increases the tendency to asphyxia and convulsions. The distension of the vessels is probably relieved by increased secretion and determination of blood to the surface. Sometimes the lungs are not properly relieved from a state of en- gorgement, which, if life be not immediately destroyed, terminates in inflammation of the substance of the lungs, or the formation of tubercles. The brain is frequently affected, not in all probability from any primary diseased action in that organ, as some have supposed, but HOOPING-COUGH. 403 from the obstructed circulation in the lungs, and the over-loaded state of the right side of the heart, preventing the free return of blood from the head. The brain, as well as every other part of the body, must likewise suffer from what may be termed the chemical condition of the blood itself, owing to the want of those natural changes which take place in the lungs,—which are prevented partly by the congested state of these organs,—partly by the want of a sufficient supply of air during each paroxysm,—and partly by the diseased condition of the mucous membrane. Treatment.—Dr. Ferrier, in his Medical Histories and Reflections, (vol. iii. p. 215.) says, that "hooping-cough has been too much trusted to the management of the nurses, and has been empirically treated, even by those physicians who have applied themselves to the par- ticular consideration of the complaint." Dr. Gregory, in his lectures upon this subject, with that frankness and candour which marked his career, used to make the following statement:—"1 think it proper for me to warn you, in the first place, that we have no cure for it." Cullen divided this disease into two stages; the first continues perhaps for three weeks; during this period, he imagines the contagion to be present, and operating on the animal frame. The second stage em- braces the whole remainder of the disease, should it last for twelve months. Dr. Mason Good says, that he believes the hypothesis to be correct; "throughout the first stage (says he,) our attention should be directed to whatever will moderate the influence of the contagious stimulus, retard the return of the convulsive paroxysms, and mitigate their violence." "Bleeding, (says Mason Good,) in severe cases, will be found ne- cessary for this purpose; but it should be avoided, except in severe cases, as spasmodic affections are often rather increased than dimin- ished by the use of the lancet; and it will in general be found better to employ blisters as a substitute." This paragraph contains almost the best proof I could bring forward, that bleeding, even in the pre- sent age, is frequently recommended and practised upon unsound principles. If bleeding be employed, it is for the prevention or cure of inflammatory, and not spasmodic action; but it is only in severe cases, according to Mason Good, that bleeding is to be used, "a* spasmodic affections are often rather increased than diminished by the use of the lancet." Now, it appears to me, that if the lancet tend to increase a slight spasmodic complaint, it will surely aggravate a severe one in a still greater degree. Bleeding is not necessary in a great majority of cases, nay, it might 404 HOOPING-COUGH. prove injurious in some, by interfering with the efforts of the consti- tution; but when the patient has fever, difficulty of breathing between the paroxysms, a near approach to asphyxia or convulsions during the paroxysm, or if he complain of a constant sense of stricture in his chest, or severe headache, 1 would recommend blood-letting, by open- ing a vein, if the patient be robust, about two years of age; and if the air tubes are not filled with mucus, I have frequently seen the best effects from opening the jugular on such occasions. It is impossible to say what quantity should be taken; it ought to be sufficient to make an impression upon the disease, or upon the system. I once saw a boy six years old, labouring under hooping-cough, who was in great danger, from the congested state of his lungs and brain. 1 requested the gentleman who was in immediate attendance, to open a vein, and to allow the blood to flow till relief was obtained. At my next visit, I found that 15 ounces had been abstracted. He bore the bleeding well, and his condition was very much improved. Next, day, how- ever, violent enteritic symptoms took place, which were not subdued till after the application, in all, of twenty leeches. This boy made a remarkably rapid recovery. It must not be understood that I would recommend the same quantity of blood to be taken from every child of that age: the case is mentioned to show that a considerable quan- tity may be abstracted without necessarily producing any bad conse- quences, and its power in controlling the disease. A similar practice must be pursued if the patient be lethargic, which, in such cases, marks oppression of the brain, and frequently precedes convulsions. Sydenham speaks strongly in favour of vene- section in hooping-cough: at page 321, (Swan's Edit.) the following statements will be found: "By this practice of venesection, and re- peated purges, and by this only, is conquered the convulsive or hoop- ing-cough; an obstinate disorder, which scarcely any other method will subdue." We must depend upon leeches in young children; as well as in older patients in advanced stages of the disease: the number of leeches to be regulated according to the circumstances noticed when treating of bronchitis. To show the advantage of leeching even at the eleventh hour, no- tice the three cases mentioned, and marked at p. 3, Willan's Diseases of London. It should be mentioned, that hooping-cough is a disease in which auscultation should be employed; by this means, we may determine whether inflammatory action be going on in the lungs,—whether it HOOPING-COUGH. 405 be general or partial,—and whether the bronchial tubes be loaded with matter; if they are loaded, we should be deterred from bleeding, for reasons so much insisted on when treating of bronchitis. After I was convinced of the morbid state of the larynx and rima glottidis, producing the hoop, or kink, as it is sometimes termed, it naturally occurred to me that leeches, applied over the part affected, would be attended with the best effects in cases where the paroxysms were severe, and threatening asphyxia. The theory may be wrong, but I can speak confidently of the success of the practice. I had an opportunity of trying it in twelve cases, in three of which the hoop never returned, although the children were previously threatened with asphyxia; all the others were relieved in the most striking manner; and had it been necessary, from the re-occurrence of urgent symp- toms, to apply them again, or had a great number been put on at first, I feel persuaded the hoop would have been destroyed in the whole. The immediate relief of this symptom, which occurred in the case of a lady, when threatened with suffocation, I shall never forget. Five children in one family were under my care, with hooping-cough; two of them had considerable dyspnoea between the paroxysms, with a tendency to asphyxia during each attack, and were exceedingly ill; blood was taken from the jugulars with extraordinary relief; a third had leeches frequently applied. These three recovered speedily. The other two had the disease so favourably at first, as not to require any treatment, except keeping the bowels open, and an occasional emetic, yet they were the most troublesome cases out of the five, and were double the length of time indisposed, v A solution of the tartrate of antimony will be found useful, if the dis- eased action in the lungs show any tendency to increase. Emetics have been much over-rated in hooping-cough. One or two may be of use when the disease is forming; and they may be exhibited now and then, in the latter stages, when the expectoration is not easy, and when we know, by auscultation, that the bronchial tubes are over- loaded with mucus. I have found an antimonial emetic the best, when there is any febrile disturbance; but should the emetic be wanted merely to unload the tubes, and particularly if the patient be weak, pwhaps the sulphate of zinc will be found preferable, as it commonly leaves no sickness or depression. Gentle purgatives are to be used for the purpose of keeping the bowels easy; great mischief is often done by the constant exhibition of drastic medicines, for weeks together. Many practitioners seem to forget, that the long continuance of powerful medicines will certainly produce great disorder of the bowels,and consequently foul evacuations. 406 HOOPING-COUGH. The antiphlogistic regimen, and confinement to one apartment, during the first part of the disease at least, are essential circumstances in the treatment. An occasional opiate, and a warm bath, will be found of service as auxiliary remedies. Blisters are necessary in very acute cases; but except in such in- stances, the counter-irritation produced by the tartar-emetic ointment, will be found most efficacious. This plan was first recommended by Autenreith. It has frequently occurred to me to observe,during epidemics of hoop- ing-cough, that those affected were sometimes attacked with measles, scarlatina, and even small-pox, the cases being much aggravated dur- ing the eruptive fever; but subsequently, upon the appearance of the eruption, the phenomenon of the hoop, which gives the character to hooping-cough, became very much moderated—in two or three cases it entirely ceased, but it generally returned when the eruption declined; an instance of which is related in Dr. Ferrier's excellent work already quoted: " Miss----, aged one year and a half, had the hooping-cough in a slight degree for some weeks. When it seemed to be leaving her, she was seized with the measles, and there was an appearance of a very large crop of the eruption. Her cough was not very troublesome, and no longer resembled the hooping-cough. On the third day she was seized with an extreme degree of dyspnoea, and a short harrassing cough, and the eruption almost entirely disappeared. The pulse be- came innumerable. Leeches were applied to the extremities, blisters were applied to different parts of the body, and every method was used to renew the eruption, but without success. The cough increased, but the dyspnoea began to relax, and at length, to my great satisfaction, the type of the hooping-cough was renewed, and my patient recover- ed by time and change of air. Not one spot of the eruption of mea- sles ran its usual course." Dr. Watt notices the same fact, and it now appears strange that so obvious a circumstance had been overlook- ed, as it is evident that the irritation was removed from the wind-pipe by the cutaneous eruption. The application of the ointment occasions an artificial eruption, exceedingly like small-pox. Autenreith considered it a certain spe- cific, when a copious crop was produced on the epigastric region; and he distinctly assures us, that the use of the ointment for twelve days produces a cure;* but the result of my practice does not authorize me to make the same statement; therefore 1 am persuaded Autenreith • I have reason to believe that Autenreith has changed his opinion, upon more enlarged experience of the remedy. HOOPING-COUGH. 407 could not have met with such severe cases as I have occasionally hap- pened to treat, particularly in the epidemic which existed in Edin- burgh about four years ago. His theory of its action, however, per- fectly coincides with mine, that " when the irritation is well estab- lished, it acted by directing the blood to the surface from the air pas- sages." It may be shortly stated, that I have seen it very serviceable in this disease, so much so, that I always have recourse to it; and it is a far more beneficial method of producing irritation in sub-acute and chronic inflammations, than that by blisters, because it is more permanent. The proportion of tartar-emetic in the ointment, is a drachm to the ounce. The antimony may also be applied, by sprink- ling it on the surface of a pitch or warm plaster. Several curious circumstances have attracted my notice, with re- ference to the external application of this remedy. In five or six cases, when it has been rubbed over the epigastric region, violent vomiting has been produced, which was proved to be owing to the antimony, by leaving off the ointment, and returning to it several times. When applied to the chest, the eruption sometimes appears on the genitals and groins; when this was first observed, I thought it had been produced by negligence; but I have since seen the same circumstance, in cases where every care was taken to prevent any ac- cidental application to these parts. When the internal disease is severe, it is in general difficult to es- tablish the cutaneous irritation by the application of the ointment I have remarked in three cases, when indiscriminately applied over both sides of the thorax, that the eruption did not appear on that side in which the diseased action was most violent, while there was a co- pious crop on the other; and in one of the cases, the line of demarca- tion was exactly in the mesial plane. Dr. Cullen, from the hypothetical notion that the disease continued during the second stage, merely by the power of habit, recommended antispasmodics or tonics; he therefore advised opiates and Peruvian bark. Dr. Hufeland likewise recommended belladonna, considering the disease to be of a true spasmodic nature; he gave it in doses of a quarter of a grain morning and evening, to children between three and six years of age. Ext. Conii was formerly in great repute. As tonics, small doses of zinc, arsenic, and nitrate of silver have been employed. In Russia, the berries of the spurge-laurel are said to be specific; they are employed, it would appear, as stimulants and anti- spasmodics. The sulphate of alumen, and garlic, have also been highly extolled. But it would be no slight task, to give a list of the remedies which have been strongly recommended. 408 HOOPING-COUGH. During recovery, it is of the greatest consequence to attend to the clothing, diet, and exercise of the patient; I have frequently traced relapses to cold feet, and to indigestible food. Laxatives are neces- sary, and the cold bath is in great estimation with some practitioners; of which last I cannot give an opinion: but I have seen the greatest advantages in this disease, and many other cases of chronic bronchial affections, from sponging the body all over with water, or vinegar and water, two or three times a-day. Change of air is extolled by some individuals, but is often productive of great mischief, by occasioning a return of the disease. It is an important fact, that during the late epi- demic, which was the most severe I have ever witnessed, all the chil- dren that were moved for change of air had the disease the longest. The children of two families, who had it in the very slightest form, were taken to the country when nearly cured; most of them had re- lapses, not only upon going away, but also on returning. The cause of relapse, in such cases, is easily explained; the patient may be moved from a warm situation to a damp, cold one; or he may be put into a damp bed; or a change of weather may take place when on his journey. It is a common practice to send hooping-cough children to play a considerable part of the day in tan-yards; but really the patho- logical notions upon which this practice is founded, are too contempti- ble to require refutation. CHAPTER III. PNEUMONIA. This disease has received various denominations, as peripneumonia, and pneumonitis; the term pleura-peripneumonia, is employed to ex- press the co-existence of inflammation of the pleura and lungs. [Pneumonia is most frequent in cold and changeable weather, espe- cially at the breaking up of winter. It has been ascertained by the observations of Dr. Clermont Lerubard, that this disease has a prefer- ence, in the proportion of three to one, for the right lung, which he endeavours to explain by the greater size and transverse direction of the corresponding branch of the pulmonary artery. With respect to the ages most liable to pneumonia, the same author draws the follow- ing interesting conclusions: viz. Adults are less subject to it than in- fants: in the former it is most common between the fifty-fifth and eighty-fifth years, and between the twenty-third and twenty-seventh years. The juvenile periods in which it most prevails, are: 1. The first or second year. 2. The thirteenth year. 3. Within a month after birth.] Phenomena.—Like other acute diseases, pneumonia commences with shivering, followed by a hot stage, which is in general pretty violent, unless in congestive inflammation, when coldness predomi- nates. There is more or less dyspnoea, and the number of respirations considerably exceeds twenty in a minute, which may be taken as about the natural standard. The breathing is in some cases very laborious, but we must be careful, as Andral properly remarks, not to allow ourselves to be led astray by the account which patients give respecting this point, for often, when the respiration is short and hurried, they will assure us that they do not feel the least impediment. Pain is not a well-marked symptom in inflammation of the substance of the lungs, the patient complains rather of a tightness in the thorax; and when pain exists, it is in general dull instead of sharp. The coughs is short, perpetual, and does not come on by fits; it is dry at Vol. I.—52 410 PNEUMONIA. the commencement, and continues very distressing and obstinate. The expectoration is scanty, viscid, and discoloured, from an admix- ture of blood; sometimes it is bright, like red currant jelly, but in general it is rusty-looking, resembling brick dust intimately mixed with viscid mucus; it is so tenacious, as to adhere firmly to the side of the vessel into which the patient spits. It is very important to attend to the colour of the expectoration, because it assists us in de- termining, not only the nature of the disease, but also its extent and severity. The expectoration is sometimes, though rarely, fetid. A gangrenous odour is perceived when the disease terminates in gan- grene. The pulse is variable in many respects, and practitioners should be very wary in depending upon it, in the confident manner so generally followed, and more particularly in pneumonia, which I have known to go on rapidly to a fatal termination, the pulse never exceeding the natural standard. Sometimes, when the inflammation is most intense, it is observed to be extremely small. Morgagni noticed the uncer- tainty of the pulse in pneumonia long ago. Many suppose that re- covery is rare when the pulse beats more than 130. Andral makes this remark, and I have no doubt, from the milk-and-water practice which is too frequently adopted by French practitioners in inflam- mations of important organs, that they may find it so. I often perceive the pulse to rise both in frequency and force, after bleeding, when the disease is fast subsiding; in many irritable constitutions it increases in frequency in consequence of considerable depletion, even when the disease is declining. With respect to the heat of skin, I have similar remarks to make; for although in many cases it may be hot and dry, yet in others it is below the natural standard. The tongue soon, in the course of this disease, becomes parched and dark-coloured; a dry glossy tongue is always a bad symptom. It has been too frequently stated in books and in lectures, that the face usually becomes livid and discoloured in pneumonia: this is an error; it being more a symptom of bronchitis, than of inflammation of the substance of the lungs. Delirium occasionally takes places, but it is far from being a gene- ral symptom; when it occurs early, it denotes danger. Mental aber- ration often occurs, however, after acute diseases in the chest and abdomen have been subdued, particularly by extensive bleeding. It in general soon yields to the use of opiates and stimulants prudently administered. PNEUMONIA. 411 Much misconception exists respecting position in, affections of the chest It is pretty generally believed that patients lie on the affected side. This is very much the case in pleuritis, and in single bron- chitis; but in pneumonia, patients are generally found on the back, particularly in severe cases. In the very severe forms of pneumonia, particularly where a large portion of the lung is inflamed, and in which extensive effusion into the air-passages takes place, or in cases complicated with considerable local congestions, or in those which terminate in gangrene of the lungs, the powers of life quickly give way, attended by symptoms which are generally denominated typhoid. In truth, this form of the disease has obtained the name of pneumonia typhoides. There is undoubt- edly such a form of pneumonia, but I object to the adjunct typhoides, as expressing erroneous ideas of the pathological condition of the body. This form of pneumonia was very prevalent during the war, among troops stationed in exposed situations along the coast, and in large garrisons where the duty was severe. The soldiers were often seized with it when exposed at night as sentinels; instead of walking about they frequently stand shivering in their sentry-boxes, the surface continues long chilled, and with a view to fortify themselves, and to produce warmth, they are in the habit of drinking ardent spirits in consider- able quantity. In the strongest subjects, I have seen the disease, under such circumstances, run its course to a fatal termination in from forty-eight to sixty hours. Remissions of this complaint sometimes take place, and it is too much the custom at such times, either to omit the necessary remedies, or to be too solicitous about supporting the strength. The only certain test of the presence of pneumonia, is that derived by auscultation; and in considering this part of the subject, the dis- ease must be divided into stages. In the first stage, or that of invasion, the crepitous rale is heard distinctly, and it resembles the noise which is produced by sprinkling finely powdered salt on the fire. This rale exists also in oedema of the lungs, and pulmonary apoplexy, but these are distinguished from pneumonia by the other symptoms. In this stage, the sound produced by percussion does not differ from that of health. When complete solidification has taken place, neither the crepitous rale nor the respiratory murmur is heard; but in the sound part of the lungs, the respiration will be heard louder than natural, which is called by Laennec "puerile respiration." Laennec says, that bronchophonism exists in certain cases, particularly if the inflam- mation be seated near the roots of the lungs, or in the upper lobes, in 412 PNEUMONIA. which places the bronchial tubes are the largest. In this second stage, percussion elicits a dull sound over the affected parts, unless the in- flammation is confined to a small central space in the substance of the lungs. In the third stage, when the infiltration of pus-like matter begins to take place in the pulmonary tissue, the mucous rale is per- ceived to a greater or less degree, which Laennec supposes is pro- duced by the introduction of the fluid into the bronchial tubes; when a large portion becomes softened, he calls it an abscess, and says that a very strong mucous or cavernous rale is perceived over its site, with pectoriloquism. When resolution takes place before the disease has run into solidi- fication, the crepitous rale becomes daily less perceptible, while the natural sound of respiration increases, and becomes gradually more distinct, and at length it is heard without the least crepitous sound; but if solidification has taken place, the cure is invariably accompanied by the return of the crepitous rSle, and then as that declines, the respiratory murmur becomes more and more distinct. I have thought it right not to be too minute in this description, by avoiding the varieties and combinations of these sounds, in the belief that they tend to puzzle the beginner. He may afterwards improve himself, and compare his observations with Laennec's statements; besides which, every professional man ought to possess Dr. Forbes's translation, which contains so much excellent matter. But it is my duty to express my fears, that few will ever arrive at that degree of perfection which Laennec possessed in the detection of all the varie- ties which he has described. I have seen two cases within these two years, in which pneumonia existed in one lung, and severe bronchitis in the other; nay, they may exist in the same lung, which will of course mask the crepitous rale. Inflammation attacks the right lung oftener than the left; it rarely affects both lungs simultaneously. The inferior lobe is much more frequently the seat of inflammation than the others. Appearances on dissection.—On examining the lungs, or any portion of them, in the first stage of inflammation, they will be found red, from the quantity of blood contained in the vessels of the part, and increased in weight. [If, however, they be carefully washed, they resume their crepitancy. This condition is called engorgement] In the second stage, that of solidification, to which Andral applies the term softening, and Laennec hepatization, the diseased part will be readily broken down between the finger and thumb, which cannot be PNEUMONIA. 413 effected in the sound state, and the lung has lost entirely the crepitous feel; if put into water, it will sink at once to the bottom of the vessel. In the third stage, the lung, when cut into, is found to contain a great quantity of reddish or grayish fluid, which oozes out from every point. [The pulmonary structure is hard and granulated, and has a peculiar pale yellow colour, often mixed with red, giving the incised surface a mottled appearance. This condition of the lung is called by the various names of suppuration, yellow hepatization, and purulent infiltration. But if complete restoration of the lung does not succeed to the pre- ceding morbid conditions, a fourth change takes place, which, unlike the others, is not susceptible of resolution. This is called indura- tion: it is characterized by a gray colour, more or less dark, though sometimes of a light, ashy tint: it presents a dense, dry consistence, often with a somewhat reticulated appearance, derived from the re- mains of air cells. When incised, it yields a sound not unlike that obtained by cutting a sponge with a knife.] The formation of an abscess in the lungs is a rare circumstance. 1 have seen one, or at most two instances of it. Laennec says he has only seen it five or six times. The granular appearance of an inflamed lung is best seen by tearing it; it seems to be agreed, by the best pa- thologists, that this is produced by the secretion of matter in the minute air cells. The appearance of an abscess in the lungs, is some- times occasioned by an effusion of lymph, which takes place on the pleura, between the lobes; adhesions form round the circumference of the effusion, and when a section of the organ is made, upon a super- ficial view it is hastily concluded to be an abscess. A tubercular excavation is also frequently mistaken for an abscess; the history of the case, the appearance of the rest of the lung and that of the parietes, will put the inquirer right. The parietes of a cavern are solid, generally hard, lined with a false membrane, and there are probably portions of broken down tubercle. The large air-tubes con- tain a secretion, commonly of a gray or reddish colour. In cases of pneumonia, when the substance of the lungs, near the surface, has been the seat of disease, the contiguous pleura almost always suffers; hence we frequently see false membrane, effusions of various degrees of consistence, and adhesions, which, if recent, will be easily separated, but if ancient, will be found firm, and sometimes when partial, very much elongated. It has been already mentioned, that inflammation of the substance of the lungs sometimes terminates in gangrene, but it is the least fre- 414 PNEUMONIA. quent termination. Cases are recorded, where the whole lung was found in this state; there are others in which one lobe only was af- fected, and in others it is more partial. Dr. Bright has given several cases, accompanied by plates of the gangrenous appearances, in his excellent " Report of Medical Cases." [Gangrene of the lung is recognized by its greenish or black colour, and by its extreme fetor. It in some instances affects the breath of the patient so as not to be mistaken; and considerable portions of the sphacelated structure are sometimes expectorated.] It has not been yet determined in what tissue the disease com- mences. Some suppose it is in the cellular membrane; others in the air cells themselves. I have not been able to satisfy my own mind on the subject, but my present impression is, that it is not situated in the air cells. Treatment.—The lancet is to be used freely, and may be employed later, with less injury to the patient, than in bronchitis; but we must be guided very much by the stethoscopic signs, by which much blood and strength will occasionally be saved to the patient. I trust no ar- guments need be used to prevent British practitioners from following the example of the French, who bleed frequently, but in small quan- tities at a time; indeed, Laennec states that he rarely repeats venesec- tion, except in the cases of patients affected with diseases of the heart, or threatened with apoplexy, or some other internal congestion; and when he does bleed, he directs from eight to sixteen ounces to be taken from the arm, and he even boasts of curing pneumonia without blood-letting. (Page 250.) Even on this side of the channel, bleeding is not always followed out as it ought to be. Dr. Mason. Good, (at p. 436, vol. ii.) in treating of pneumonia, says, " In this case bleeding should be prompt and co- pious, at least to eighteen or twenty ounces, and repeated twelve hours after if necessary." 1 object strongly to this recommendation, both as to the quantity of blood to be drawn, and the long interval between the bleedings; but the reader is referred to my former observations on that subject. Late in the disease, bleeding must, however, be used in small quantity, and with the greatest caution. The great use of auscultation in treating pneumonia, is, that in general, not only is the practitioner accurately informed with regard to the extent of the disease, but he is told if the sanative process have commenced, when bleeding is, to say the least of it, a doubtful remedy, and in many cases may do harm, by interfering with the powers of the constitution. Nevertheless I am PNEUMONIA. 415 persuaded, from experience in treating the disease, and from exami- nations after death, that much more mischief is done by bleeding too little, than by bleeding too much; but I am not an advocate for the heroic practice of taking seventy or eighty ounces of blood at one operation; the largest bleeding which I believe I ever took in my life was fifty-six ounces. In general if the operation be properly per- formed, thirty or thirty-five ounces will suffice, but the patient should be seen again in the course of two or three hours.* I have the history of a case before me, in which one hundred and ninety-two ounces were taken from one individual; but lam per- suaded, that if he had lost two-thirds less it would have been better for him. Several months afterwards he was weak and miserable, and it appeared very doubtful that he ever would regain his health. On one occasion, early in life, I very nearly lost a patient, from whom 1 had taken, at different times, in the course of four days, one hundred and twenty ounces of blood, but who recovered after the exhibition of stimulants; and within the last ten years, I have seen several cases where considerable injury had been inflicted by very large bleedings, the medical attendants having allowed themselves to be misdirected by the continuance of dyspnoea, which increased after each abstraction of blood. It was evident that this was owing to a want of sufficient blood in the system. In one instance, the patient was on the brink of the grave, with a pale, sunk countenance, and cold extremities; the strongest stimulants were administered, along with opiates. All these cases eventually recovered. Antimony is of essential use in the treatment of pneumonia; but I would reverse the rule laid down by Laennec, and state that it is to be used as an auxiliary remedy only. Cullen, (in the 371st para- graph,) in alluding to antimony, says, that he has found it useful to exhibit nauseating doses, and in a somewhat advanced state of the disease, that such doses proved the best means of expectoration. The Italian physicians, and particularly Rasori, first exhibited the emetic tartar in very considerable quantity, as a cure for inflammatory dis- eases. Rasori, it would appear, gives twelve grains during the first day, and as much during the night; if the disease be already much advanced, he gives forty or sixty grains during the twenty-four hours, and goes on increasing the dose, till it amounts to several drachms. For much interesting information on this subject the reader is refer- [* In some parts of the United States this will be considered a very free use of the lancet. See addenda at the end of this chapter.]—Ed, 416 PNEUMONIA. red to a long note by Dr. Forbes, in his translations of Laennec, p. 263. Laennec, who adopted the Italian practice in France, immediately after a small bleeding, gave one grain of tartar-emetic in three ounces and a half of fluid, which he repeated every second hour for six times. He then omits the medicine for seven or eight hours, if the symptoms be not urgent; but if the oppression become great, with affection of the brain, or if both lungs or one whole lung be attacked, he con- tinued the medicine uninterruptedly, until an amendment took place, indicated by the stethoscopic signs. " Sometimes even, particularly when most of the above-mentioned unfavourable symptoms are com- bined, I increase the dose (says he) of the tartar-emetic, to a grain and a half, two grains, or even two grains and a half, without increasing the quantity of iheavehicle. Many patients bear the medicine without being either vomited or purged." (Translation, p. 251.) Indeed it is an extraordinary fact, that the more severe the disease, the less visible effect has antimony on the patient. This observation applies not only to pneumonia, but to bronchitis, in which very large doses do not produce vomiting, and which is very difficult to bring about by any means. My experience in the use of antimony, and the re- sult of the experiments which were published in the Lancet, (vol. ii. p. 536,) lead me to conclude, that vomiting is more speedily produced by a small dose dissolved in a large quantity of water, than a large dose of the drug mixed with a little sugar; but in the latter case, the nausea, is more severe, and of longer continuance than in the former. Laennec states that its most constant effect is the rapid resolution of inflammation, and sometimes the equally speedy absorption of the in- flammatory effusion. The latter effect is proved in the case of Pem- berton, the subject of my second experiment, who was affected with "induration and enlargement of the testicle, which was of a scirrhous hardness." His first dose of the medicine was twelve grains, in half an ounce of water, taken upon an empty stomach; vomiting was not produced for fifty-five minutes. On the following day, the report states that the enlargement of the testicle was found to be diminished about one-third. In some days afterwards, he again took twelve grains in an ounce of the decoction of bark: vomiting did not take place till the expiration of an hour. Again he took, sometime after, twenty grains in a little sugar, and suffered much less pain and nausea from this quantity than during the preceding experiments. On the following day, the report states, that "the enlargement of the testicles continued to decrease:" in a short time it was found to be consider- PNEUMONIA. 417 ably reduced, and was soon quite cured. This man had been many months on the. sick-list; the disease had previously resisted all the usual remedies, and the question of extirpation was agitated. I have no faith in digitalis in the ordinary doses, at least during the acute inflammatory stage. Blisters will be found useful, under the same restrictions as described in bronchitis. I have seen the best effects from opiates, during the decline of the disease, in allaying ir- ritability, and violence of the cough, as well as by producing sleep. Formerly great objections were entertained against the employment of purgative medicines in this disease; but these are now removed. It is certainly necessary to keep the bowels open; for which purpose I generally give a smart dose of physic immediately after the first bleeding, and some hours before the exhibition of the tartrate of anti- mony, and assist its operation by means of injections. Subsequently, if the antimony do not operate upon the bowels, evacuations should be produced daily by injections, as medicine taken by the mouth will not be retained on the stomach. The regimen, it is almost unnecessary to remark, should be strictly antiphlogistic, and with a view to prevent vomiting during the anti- monial treatment, as little liquid as possible is to be allowed. During recovery from all acute diseases of the chest, visiters should be ex- cluded, as talking, even in an under tone, is injurious to the patient. [The treatment of pneumonia in the United States, is, for the most part, of a less depletory character than that advised in this chapter. Although with us the disease is violently inflammatory, the experi- ence of both public and private practice, is in favour of a more moder- ate use of the lancet than that here recommended. From fourteen to twenty ounces of blood may be at first taken, and it is often necessary to repeat the venesection in a few hours: but in very many cases, if the general bleeding be followed at once by free cupping over the affected part of the chest, and if a large blister be applied as soon thereafter as the condition of the patient will allow, the disease will yield without difficulty. Such has been the fact even in our Alms- house Hospital, where pneumonia is very prevalent in the winter and spring, and occurs in miserably broken constitutions. Mercurial pur- gatives, with antimonials in small doses in mucilaginous drinks, and the occasional addition of opiates, are the principal adjuvant remedies.] Vol. I.—53 CHAPTER IV. PLEURITIS. Phenomena.—As in other acute diseases, this is generally ushered in by a cold stage of greater or less severity. The patient complains of fixed pain in the side, over which he can place his finger, which is described as a stitch, catching and interrupting his breathing every now and then, particularly when he fills his lungs beyond a certain extent. The pain is sometimes so severe, that the patient, in describ- ing it, says it is like~a stab with a sharp instrument. In pleuritis the breathing is difficult and anxious; but it is short, and not so heavy and oppressed, in the first instance at least, as in inflammation of the other tissues. There is also cough, which aggravates the pain very much; the expectoration is thin and watery, very different from that in pneumonia and bronchitis. The pulse, generally speaking, is quicker and harder, and the heat of skin is more intense than in pneumonia and bronchitis; but inflammation of the pleura, the most intense and extensive, may take place, and terminate fatally, without being de- tected by these symptoms. At present, 1 may remark, with regard to the heat of skin, that it is greatest over the thorax in pleuritis, and very often I have felt it much increased over the seat of the disease, at which point external pressure is much complained of. The tongue, however much furred it may be, soon becomes dry. The urine is scanty, and high-coloured. The functions of the brain are also some- times disturbed. There is a painful affection, commonly ascribed to the intercostal muscles, and termed pleurodynia, which gives rise to all the symp- toms above described, and it is impossible to determine the one from the other but by auscultation. A symptomatical physician may now and then guess right, but it is only to be considered as a guess, for three such cases have occurred to me within a very short space of each other, one only of which proved to be pleurisy, although from the slightness of the symptoms, and the character of the patient, who PLEURITIS. 419 was always complaining for trifles, I least expected to find it. Dr. Ferrier, (at page 86, of his 2d vol.) states the case of a boy, who died from extensive inflammatory action of the pleura, and effusion into the pericardium, who nevertheless had " no cough, no difficulty of breathing, nor pain in his breast, and I could not find, (says Dr. Fer- rier,) from the most careful inquiry, that he had ever made such com- plaints. There was great paleness over the whole skin. He was torpid; without delirium, or the symptoms of oppression common in typhus." In his observations upon this case, he states, " In this case, an active inflammation through the whole extent of the pleura, pro- ducing exudation and adhesions, was not indicated by any symptom during the continuance of the complaint." Stethoscopic signs.—In pleurisy these signs are of less importance in directing treatment, than in pneumonia and bronchitis, because there is no particular sound elicited by the stethoscope in pleurisy, till the inflammation has run to its ultimatum, and has produced effu- sion; but great advantage is nevertheless obtained from the negative proof afforded by auscultation, which will inform us if either of these two diseases exist. Independently of this, however, the stethoscope is of use in pleuritis, by informing us when effusion really exists, which, it is admitted, cannot be done by the ordinary signs. In the early stage of pleuritis, the respiratory murmur is less distinct, but not otherwise changed, over the site of the diseased part. When effusion takes place, the sound in the lower part of the chest becomes dull, and when the patient is desired to speak, his voice is heard through the stethoscope, at the diseased part, small, sharp, and very tremulous, to which Laennec has given the name oegophony. When the effusion is very extensive, and in considerable quantity, the sound elicited by percussion is very dull, and the sound of respiration is not hard, un- less at points where old adhesions exist, which prevent the lungs from being compressed and forced away from the ribs. On examining the naked chest, when there is great effusion, that side of the thorax is perceived to be the largest; the ribs are found more distant from each other, and more fixed during respiration, that on the healthy side. OZgophony exists in hydro-thorax also; but this is of little conse- quence, as the general history of the case, and local symptoms, must. always be appealed to, and weighed as necessary parts of the evi- dence in each case. It must be recollected, that pneumonia and pleurisy frequently co- exist; but neither is that circumstance of much consequence, being both inflammatory diseases, and requiring the same general remedies. 420 PLEURITIS. Appearances on dissection.—The pleura, when inflamed in the first stage, shows a great number of red points, which are sometimes produced by slight ecchymosis in the cellular membrane, beneath the pleura; red vessels are also frequently observed, and the spaces be- tween the vessels, and between the punctae, appear natural. The pleura is rarely found thickened, although it may appear to be in that state, the deception arising from the deposition of coagulable lymph, the removal of which shows the pleura without alteration of structure. It has frequently occurred to me, in chronic pleuritis, to be able to separate what appeared to be two and even three layers of new mem- brane. There is often found extensive effusion of a serous fluid like whey, exactly similar to that seen in the abdomen in peritonitis. Sometimes we find the lungs attached to the pleura lining the general cavity, by an intermediate deposition of lymph; when recent, the parts are easily separated, and there is the best evidence for believing that the new matter becomes organized. Occasionally, (particularly in chronic pleuritis,) we find both the pleura pulmonalis and costalis in- flamed, and much thickened by the deposition of lymph, with or with- out an effusion of serum mixed with lymph, which resembles thick pus; masses of lymph, weighing half an ounce or more, are sometimes found in the bottom of the cavity. If there be no old adhesions, and the effusion be large, the lung will be found greatly compressed and lying close to the spine, perhaps without any alteration of the struc- ture. Mortification is one of the rarest results of inflammation of the pleura. Ulceration is also rarely met with; 1 have seen two instances of this lesion; the ulcerations were extensive, and affected not only the pleura pulmonalis, but the costalis also, as well as that part which forms the mediastinum. In one case, of which I have a very beauti- ful representation, on exposing the contents of the thorax, six large ulcerated spots were observed upon the anterior surface of the right lung, one of which was two inches in length, and above an inch in breadth, occupying almost a regular oblong space, whilst the rest ap- proached to the circular form. There were eight or nine ulcerations on corresponding parts of the pleura costalis, of an oval shape,—one very large; there was also one above two inches in length on the me- diastinum. The pleura was very vascular, and the margin of each ulceration was red, thickened, and somewhat indurated; no trace of the pleura could be perceived on the ulcerated surfaces, except here and there a small ragged portion was met with. The ulcers were covered with a puriform matter. The lung was somewhat compress- ed, and on making incisions through the ulcerated parts, its substance PLEURITIS. 421 was found to be red and hard; a state of the organ which extended to no great depth, in some places not greater than a line, and no where more than about the third of an inch; the rest of it being engorged. In this case, which I did not see till within a few hours of the fatal termination, no suspicion was entertained of the true nature of the affection; the treatment was conducted by two physicians, for whose talents and practical experience I entertain the highest degree of re- spect; but it may be mentioned that neither of them used the stetho- scope. At first, it was supposed there was some pulmonary affection, for which the lancet was used; but very soon the vital powers began to sink, after which the disease was denominated typhus fever, and treated accordingly. Treatment.—Little need be said respecting the treatment of pleu- risy, farther than that bleeding is to be had recourse to repeatedly and copiously. Leeches applied over the seat of the pain, are often of very singular benefit; in some cases no other means of detracting blood will be required. Antimony may be employed, together with laxatives and an occasional opiate. The antiphlogistic regimen is ab- solutely required, and blisters are often useful. In pleurodynia, a warm bath, and a dose of Dover's powder, will, in general, be sufficient to mitigate the violence of the pain; a bandage, placed tightly round the thorax, is serviceable, by preventing the motion of the ribs. A good practical man, however, will always be found to act on the safe side; and when in doubt, he makes it a rule to give the patient the benefit of. that doubt, by employing the means required in the more severe disease. Dr. Rush, in the 4th volume of his Inquiries, in considering the probability of a connection between the morbid excitement at the neck of the bladder, and the safety of more vital parts of the body, states, that "the idea of this connection was first suggested to me four and twenty years ago, by the late Dr. James Leiper, of Maryland, who informed me he had sometimes cured the most dangerous cases of pleurisy, after the usual remedies had failed, by exciting a stranguary by means of the tincture of Spanish flies, mixed with camphorated spirit of wine." Page 35. I have only further to state, that relapses, in all inflammatory com- plaints of the chest, are generally to be attributed to imprudence in diet, and to the too early exertion of speaking; therefore it is always safer to continue the antiphlogistic regimen a day or two longer, than to allow food to be taken a single day too soon. The practitioner finds himself often foiled on both these points, by the imprudence of patients and attendants; under such circumstances, it is an excellent 422 CHRONIC PLEURITIS. plan to keep the patient slightly under the influence of antimony, which will prevent the generality of people from feeling much incli- nation to eat or speak. CHRONIC PLEURITIS. < According to Laennec, there are three kinds of chronic pleurisy:— 1st, That which is chronic from its origin; 2dly, Acute pleurisy be- coming chronic. 3dly, Pleurisy complicated with certain organic productions on the surface of the pleura. I shall follow a different plan in this work, and first describe the chronic pleurisy which ter- minates in empyema, and afterwards that which terminates in perma- nent contraction of the chest. Empyema.—This term implies the existence of matter in the chest, the effect of chronic pleurisy, or the bursting of a pulmonary vomica into the cavity of the pleura; of this last affection I shall speak, after treating of phthisis.—Whether the empyema be produced by a pleu- risy which was chronic from the first, or considered as the termina- tion of the acute form of the disease, the effect is the same,—there being generally dyspnoea, the breathing being easier in the erect pos- ture; dry tickling cough; hectic fever; enlargement of the side of the thorax when compared with the other, the intercostal spaces being increased; the patient cannot lie except on the diseased side: some- times fluctuation may be felt. This form of the disease appears to have been well known to Hippocrates, although he confounded it with pneumo-thorax.* Stethoscopic signs.—Percussion gives a dull sound, and the re- spiratory murmur is not heard, which will be puerile on the other side; but here we must recollect, that the effusion may be double, although this is a rare circumstance. Treatment.—When effusion is discovered, the sooner the chest is tapped the better; as remarkable recoveries have taken place, showing that there is still some hope. There is, however, some difference of opinion respecting the propriety of drawing off the matter all at once, or by degrees. Although my experience on this subject is not great, yet I am induced to believe that the more quickly the matter is re- moved the better. A most interesting case, successfully treated by Dr. Pitcairn, of Edinburgh, is recorded in the 2d vol. Edin. Med. * An excellent paper on Empyema, &c. by Dr. Duncan, jun. in the 93d No. of the Edin. Med. and Siyg. Journal. CHRONIC PLEURITIS. 123 Chir. Transactions, p. 229. During recovery, we should be on our guard to prevent, by means of regimen, a renewal of the inflammation. Instances are upon record, in which the matter found its way out of the chest through the parietes, and through the bronchial tubes also. The other kind of chronic pleurisy to which I wish to allude, is that which leads to permanent contraction of the chest. The de- formity is readily perceived on looking at the naked chest; the af- fected side is found to be narrower than the other, and the length is equally diminished in consequence of the ribs being drawn closer to each other. [It will mostly also be observed, that in proportion as the ribs are retracted in front, the corresponding scapula projects be- yond its fellow.] The muscles are also much smaller, which adds to the disproportion of the chest. The patient leans to the affected side; in many cases so much so, as to make a patient appear as if he had an affection of the spine; this happened in Dr. Pitcairn's case above quoted. Laennec states, that it was long before he had an opportunity of ascertaining to what cause the contraction of the thorax was owing, which he at last discovered to depend on fibro-cartilaginous adhesions, between the pleura pulmonalis and costalis. He nevertheless thinks that a degree of contraction is produced by the common cellular ad- hesions when very extensive; for he'states,'that in every case wherein he found one lung adhering throughout, by means of a pretty copious cellular tissue, he has always thought that side of the chest narrower than the other. 1 have seen several cases of contraction of the chest from this cause;* one where the contraction was in the left side, and evidently connected with some affection of the heart and pericardium. Some years ago, when accidentally at Chichester, Dr. Forbes, the ac- complished translator of Laennec's work, was kind enough to take me to visit a patient who was affected in this manner, and in whom the contraction succeeded, if I remember rightly, to a severe attack of acute pleurisy.* [Contraction of the chest also occurs independent of adhesions. Thus, when pleurisy has been attended by copious effusion, the fluid presses the lung upwards, and more or less impedes its functions. If, after this condition has lasted a considerable time, absorption takes place rapidly, the lung does not expand with suffi- cient celerity to fill the threatened vaccuum, but the ribs on the con- trary collapse upon the lung. The consequent deformity is often ob- literated during the growth of children, but is for the most part irre- trievable in adults.] * Hydro-thorax will be treated of in the chapter on Dropsy, in the 2d vol. CHAPTER V. HOEMOPTYSIS. This term signifies a discharge of blood from the air-passages, which occurs principally under three forms:—1st, A general exhala- tion from the mucous surface of the bronchial tubes. 2dly, From • apoplexy of the lungs. 3dly, From an erosion of a blood vessel in a tubercular excavation in the lungs, and which falls to be considered when treating of phthisis. [To these may be added a fourth form, which take place from the granulations of abscesses.] The first variety is the most common, and is not generally attended with much danger. It frequently attacks women at the monthly pe- riods, when the menstrual discharge is more scanty than usual, or is entirely suppressed; girls are often so affected at the age of puberty, immediately before the catamenia should appear; but the male sex is not exempt from it. I have seen it appear in men, upon the dry- ing up of an old sore, or the disappearance of a long-standing eruption; it sometimes succeeds to mental affliction. The discharge is generally preceded by some constitutional disturbance; the bowels are found out of order, the tongue foul; the patient has passed somewhat restless nights, with more or less fever, and feels most comfortable in the half- erect posture. At last there is cough, which is often constant and distressing, with more or less dyspnoea, particularly when moving about. The pulse varies much according to the age and constitution of the patient, and the period of the disease; but generally it is quick and bounding. I have commonly seen this form of the disease creep on insidiously; but at the same time it must be confessed, that a bloody expectoration sometimes takes place suddenly, immediately after the occurrence of cough and dyspnoea. The expectoration has a peculiar appearance; it resembles red currant jelly,—sometimes not so much tinged, but like a mixture containing different proportions of apple-jelly with red currant; it is sometimes copious, but in gene- ral the quantity discharged is moderate. Sometimes, however, the expectoration is of a mixed kind, small masses of coagulated blood HEMOPTYSIS. 425 being observed. Occasionally, indeed, the discharge is quite bloody, but moderate in quantity, and very frothy; but in some cases pure blood in large quantities is discharged. On all occasions, it is much increased by every exertion, either of the body or the voice. Accord- ing to Laennec, the chest is perfectly sonorous. On applying the ear, the crepitous rale is not heard as in pulmonary apoplexy; but there exists a mucous rale, which is more or less extensive, according to the quantity of blood effused into the air-passages. Appearances on dissection.—I have never been present at a dissec- tion of a person who died of this form of the complaint; but Laennec states, that, "on examining subjects who have died of bronchial haemorrhage, or while labouring under it, more or Tess of coagulated or fluid blood, is found in the bronchia. On the surface of the coagula, we sometimes observe fibrinous concretions in the form of polypi. The mucous membrane is commonly a little softened, and impregnated or tinged with blood through its whole depth."' Treatment of the first variety.—This is in general very simple. Blood-letting is not necessary, unless the patient be plethoric, or there are marks of an irregular determination of blood, which we wish to re- move from the lungs, when one bleeding will in general suffice. The leading points to be attended to, are the following:—Perfect rest, silence, abstinence from every stimulant; a very small quantity of food is to be taken at a time. The patient should be placed, if possible, in a large, cool apartment, with light clothing; and a pretty smart action is to be kept up on the bowels, by means of frequently-repeated laxatives. If, however, the discharge still continue, with a strong pulse, small doses of the tartrate of antimony are to be used so as to produce some degree of nausea; but the most potent remedy with which I am acquainted, is the acetate of lead, which I commonly pre- scribe in such cases, in doses of two, three, or four grains every third or fourth hour; but I never use it till the plethora is considerably re- duced. A great many other astringents have been employed, as sul- phuric acid, alum, kino, the bark of the pomegranate, and the ratany root. [To these may be added the popular remedy of common salt.] The second variety, or that which proceeds from pulmonary apo- plexy, is marked by a greater degree of haemorrhage, which is some- times so violent as to resist all medical treatment. The pathology of this variety of haemoptysis, was, as Dr. Forbes remarks, entirely un- * Forbe's Translations, page 128. Vol. I.—54 426 HEMOPTYSIS. known before the publication of the first edition of Laennec's work, although some obscure notices had been given by others before that period. Symptoms.—This disease is, in general, preceded by symptoms common to haemorrhages from other parts of the body; such as chilli- ness; cold extremities, followed by flushes of heat and redness of the cheeks; headache; quick and extremely hard pulse,—palpitation of the heart. The discharge from the lungs is attended with dyspnoea, —suffocating feeling in the chest, sometimes, according to Laennec, with great pain,—oppression at praecordia,—sense of rawness of the throat, and a saltish taste in the mouth. The expectoration consists of bright and frothy, or black and clotted blood, sometimes intermixed with saliva, or a little mucus. The pulse is frequent and full, with a feeling of vibration; the heat of skin is not considerable; sometimes I have seen profuse perspiration. The spitting of blood is copious, and returns by fits with cough, oppression, anxiety, intense redness or ex- treme paleness of the face, and coldness of the extremities. These last-mentioned symptoms are the most frequent and striking. When the haemorrhage is very great, says Laennec, " it comes on sometimes with a very moderate degree of cough, and is accompanied by a con- vulsive elevation of the diaphragm, like that which takes place in vomiting. This accounts for the expression, "vomiting of blood," which is used by most persons who have suffered in this way. He thinks that part of the discharge very often comes from the stomach, and that haematemesis frequently co-exists with hoemoptysis. Laennec has known ten pounds of blood lost in this manner, in forty-eight hours, by a young man who died under the haemorrhage. In other cases, he has seen about thirty pounds lost in a period of fifteen days; but, in general, the discharge does not exceed twelve or fifteen ounces in twenty-four hours, and in some cases, not three or four. Percussion, in general, gives no information. Auscultation, how- ever, furnishes us with two principal signs of the pulmonary apoplexy, —the want of the sound of respiration over a circumscribed space, which may be more or less extensive, and a crepitous rale round this space. Appearances on dissection.—Having had but a few opportunities of observing these appearances, I shall take the liberty of copying Laennec's account. " Some part of the pulmonary system has under- gone great changes, being indurated to a degree equal to the most complete hepatization. The induration, however, is very different frpm the inflammatory affection of the lungs distinguished by this term. HEMOPTYSIS. 427 It is always partial, and scarcely ever occupies a considerable portion of the lungs; its more ordinary extent being from one to four cubic inches. It is almost always very exactly circumscribed, the indura- tion being as considerable at the very point of termination as in the centre. The pulmonary tissue around is quite sound and crepitous, and has no appearance whatever of that progressive induration found in the peripneumatic affection. The substance of lung is indeed often very pale around the hoemoptysical induration; sometimes, however, it is rose-coloured, or even red, as if tinged with fresh blood; but, even in this case, the circumscription of the indurated part is equally distinct. The indurated portion is of a very dark red, exactly like that of a clot of venous blood. When cut into, the surface of the in- cisions is granulated, as in a hepatized lung; but in their other charac- ters, these two kinds of pulmonic induration are entirely different. In the second degree of hepatization, along with the red colour of the inflamed pulmonary tissue, we can perceive distinctly the dark pul- monary spots, the blood-vessels, and the fine cellular intersections; all of which together, give to this morbid state the aspect of certain kinds of granite, as has been already observed. In the induration of hoemoptysis, on the contrary, the diseased part appears quite homoge- neous, being altogether black, or of a very deep brown, and disclos- ing nothing of the natural texture of the part, except the bronchial tubes and the larger blood-vessels. The latter have even lost their natural colour, and are stained with blood. The veins of the affected part, and also those adjoining, are sometimes filled with a firmly coag- ulated and half-dry blood. In scraping the incised surfaces of these parts, we can detach a small portion of very dark, half-congealed blood, but in a much less proportion than we can press out the bloody serum from a hepatized lung. The granulations on the incised sur- faces have also appeared to me larger than in cases of hepatization. Sometimes the centre of those indurated masses is soft, and filled with a clot of pure blood. " This morbid affection is evidently produced by an effusion of blood into the parenchyma of the lungs—in other words, into the cells. From its exact resemblance to the effusion that takes place in the brain in apoplexy, I have thought the name pulmonary apoplexy very appli- cable to it. Some examples have occurred of sudden death from hoe- moptysis, wherein the substance of the lungs was found lacerated, and containing clots of blood. Corvisart mentions one extaordinary case of this kind, in which the extravasation had lacerated the lung, and fill- ed the cavity of the pleura. The hoemoptisical engorgement above 428 HEMOPTYSIS. described, is only a lesser degree of the same affection, in which the effused blood (still in some degree under the influence of vital action,) coagulates in the air-cells, in such a manner, as to form an intimate union with the pulmonary tissue, very different from what would be produced by the mere physical coagulation of the blood. We some- times find two or three similar indurations in the same lung, and fre- quently both lungs are affected at the same time. They take place most commonly in the central parts of the lower lobe, or towards the middle and posterior part of the lungs; it is consequently on the back and inferior part of the chest, that we ought to search for them with the stethoscope. "This affection is as easily distinguishable from the congestions that take place after death, as from the alterations produced by the peri- pneumony. The sanguineous congestions of the dead body consists of an accumulation of blood intermixed with serum, often spumous, which flows plentifully on an incision of the part, and tinges the lungs of a livid or vinous colour. Being the mere consequence of gravitation, the engorgement is found most considerable in the most depending parts of the lungs, and gradually lessens towards the supe- rior parts. Where most engorged, the part still retains some crepita- tion, and the incised surfaces are never granulated, even when the congestion is so great as to destroy the spongy character of the lung. By washing, we can, in every case, remove all the red, and restore the lung to that sort of flaccidity which it possesses when compressed by a pleuritic effusion. The engorgement of hoemoptysis, on the con- trary, is accurately circumscribed, very dense dark-red or brown, granulated, and almost dry when incised, and grows pale by washing, but without losing any part of its consistence. Whatever may be the severity of this disease, resolution seems to take place with consider- able facility, since we find a great many cases of recovery after severe hoemoptysis. I have not had many opportunities of tracing the pro- gress of this resolution by morbid dissection; but in the small num- ber of cases which I have met with, it has appeared that the indurated parts passed successively from dark-red, to brown and pale-red; and that, in proportion as the colour faded, the parts lost their granular texture and their density. I do not think that this obstruction is fol- lowed, at least constantly, by oedema, as is the case with the obstruc- tion of peripneumony. When the resolution is complete, it leaves no trace of disease in the pulmonary substance, since I have never been able to find any vestige of the induration in subjects who have been HEMOPTYSIS. 429 affected with severe haemorrhage at a period of some years—or only some months—anterior to their death."* Treatment of the second variety.—The treatment depends very much upon the condition of the lungs, the age and constitution of the patient, and upon the quantity of blood already lost. The plan of bleeding, in every case of bloody discharge from the lungs, is very bad; because it is bleeding for a name, without reference to pathologi- cal considerations. In this variety, however, copious venesection is to be employed early, and carried to such an extent, as will render a repetition generally unnecessary. It is employed to reduce plethora, and to moderate the action of the heart and arteries,—to change the determination of blood quickly,—and, on some occasions it is to be carried the length of inducing syncope. It requires considerable ex- perience to act properly on such occasions; for sometimes, in very stout plethoric people, we ought to take away a large quantity of blood, say to the extent of three or four pounds; and to prevent syn- cope from taking place before we obtain a sufficient quantity, the op- eration should be performed when the patient is in the recumbent posture. When we wish to induce syncope, or to alter the tide of the circulation as quickly as possible, and at a small expense of blood, a large orifice should be made, or a vein in each arm opened at the same time, and the patient kept in the erect posture. It is curious to observe, that Laennec recommends bleeding in large quantities, even to syncope, in this complaint, and pursues quite an opposite course in pneumonia. With regard to bleeding in this disease, he uses the following language:—" But the extreme danger which at- tends the hoemoptysical induration, and possibility of its resolution, ought to make us boldly use copious venesection from the onset of the disease. One blood-letting of twenty or twenty-four ounces on the first or second day, will have more effect in checking the haemor- rhage, than several pounds taken away in the course of a fortnight. It is evep beneficial, in general, to indace partial syncope by means of the first bleeding. In cases of this kind, the fear of exhausting the patient's strength is without grounds, since we know that the most copious venesection falls short of the loss of blood sustained from pulmonary hsemorrhage, in young and robust subjects, even in the course of a few minutes; while the debilitating effect of the haemorrhage is infinitely greater than the loss of blood produced by the lancet." * Forbes' Translation, page 184. 430 HEMOPTYSIS. After great losses of blood, whether by the lancet or otherwise, the state of the circulation must be carefully watched; much more care- fully, the larger the quantity lost; and we must take care not to lose the vantage ground by subsequent imprudence on the part of the practitioner, or on that of the patient. For this purpose, perfect rest, quietness, and complete silence, are to be enjoined; cool air is to be freely admitted; but I have seen great injury done by keeping the temperature of the body too low, for too long a period, which pro- motes the tendency to internal congestions. One bleeding ought in general to suffice, provided it be carried far enough. The circulation is afterwards to be controlled by nauseating doses of antimony; the rigid employment of the antiphlogistic regimen, and the exhibition of laxatives, are to be pursued. But if the patient have lost too much blood before we are called, or should the haemorrhage continue after copious bleeditig, then we must trust to the effects of the acetate of lead, in considerable doses, which I have seen useful in suppressing haemorrhages, which were afterwards proved by dissection to have proceeded even from a ruptured blood-vessel in the lungs. Drawing blood by leeches, is scarcely ever admissible, unless to mitigate some local pain in the chest, which, however, is better ef- fected by a blister. If the patient be thirsty, acidulated drinks may be allowed. Some have recommended ice to be piled upon the chest in such cases, which surely must be a dangerous practice. [Yet the temporary application of ice to sensitive parts, especially to the genitals, will check haemoptysis when all other means have failed. This plan, in plethoric persons, is scarcely admissible until active general remedies have been premised: but it is adapted to deli- cate constitutions, and especially where the bleeding has frequently recurred.] Hoemoptysis sometimes takes place in consequence of aneurism of the aorta, of which I have seen three cases, all of which proved fatal; the blood found its way into the bronchial tubes, by absorption and ulceration of that part of the lung which came in contact with the aneurismal sac, and which, in fact, formed at last a part of the sac itself. In two of these instances, the parts were strengthened, and life preserved for a considerable time, by the usual deposition of co- agulated blood found in aneurisms, till at last the fatal hoemoptysis occurred, and the patients died in a few minutes. In the third case a deposition of coagulable lymph had, perhaps for a longtime, prevented the eruption of blood, which at last, however, took place, but soon HEMOPTYSIS. 431 suppressed by moderating the force of the circulation by bleeding; but it returned repeatedly, and at last carried off the patient, almost in a moment. On dissection, a considerable portion of the lung was found injured, but the loss was partly repaired by a thick and dense layer of coagulable lymph, the upper part of which was found de- tached, at which point the blood had passed into the bronchial tubes. I have seen hoemoptysis take place, probably from hypertrophy of the heart; and I once witnessed a dissection, where complete apoplexy of the whole of one lung had taken place, the other having been for years, as far as we could judge from the history of the case, in the most perfect state of hepatization, from chronic inflammation. The patient complained occasionally of attacks of asthma, and experienced much embarrassment in going up hill or ascending a stair. He died in a moment, after discharging a mouthful or two of blood. A draw- ing, showing the external appearance of both lungs, and their internal structure, is in my museum. CHAPTER VI. PHTHISIS PULMONALIS. Phenomena.—If a person be frequently apt to take cold from slight causes,—if his lungs be easily irritated at all times so as to pro- duce coughing,—is of spare habit and ill-formed thorax,—and if many of his predecessors have died of phthisis, considerable apprehensions ought to be entertained for his safety. Care and good management may, however, be useful in meliorating symptoms and warding off danger. If an individual have laboured under bronchitis, peripneumony, or pleurisy, beyond the ordinary period, in spite of the usual means em- ployed early, tubercles may*be suspected to exist already, or their for-. mation is to be dreaded; and if any predisposition have been shown, the result of the case will be still more doubtful. If he continue coughing, losing flesh, and looking pale, the pulse becoming more and more frequent, with increasing dyspnoea, and expectoration of a copious mucus, almost colourless and semi-transparent, the chances are much against him; particularly, if the sound elicited by percussion be dull,—if the respiratory murmur be not heard at all, or indistinctly, the patient may be almost declared to have confirmed phthisis. If the skin becomes discoloured, with diminution of flesh,—if shooting pains be felt in the breast and back, between the clavicle and scapula,—if there be frequent cold shivering,—if the nails are turned in, the pulse still increasing, with viscid perspirations,—if the expectoration be cream-coloured, looking granular, adhering firmly to the vessel—or if it should look bloody, or like milk-and-water, with a cheesy-looking matter floating on it, a still worse opinion of the case may be formed. If, however, he be troubled with hoemoptysis now and then,—if the expectoration continue for some time,—if his hair look mangy, with increasing dyspnoea and weakness,—and if the sound in the upper part of the chest, instead of being dull as before, is observed to become clear,—if a gurgling noise is heard upon applying the ear to the chest, PHTHISIS PULMONALIS. 433 or if, when the person speak, the sound of the voice appears very clear through the stethoscope,—the person may, without any doubt, be pronounced to be affected with pulmonary consumption. Sometimes the first and most important symptom throughout the affection, is hoemoptysis. I have seen some cases where diarrhoea came on with the cough, and continued throughout the rest of the pa- tient's life; in general, however, it exists for the last six weeks or two months only. I have rarely seen a person live beyond twelve weeks, after the first appearance of diarrhoea, accompanied by griping pains in the bowels. Sometimes the bowel-complaint alternates with violent perspirations, but occasionally they co-exist. Sometimes an indivi- dual has no pain from the beginning; at others, the pain is occasion- ally very acute, not only in the bowels, but in the thorax. Occasion- ally there is little cough, and little or no expectoration, the mildness of the symptoms causing great uncertainty in forming a diagnosis; and truth compels me to acknowledge, that auscultation and percussion cannot always remove the mystery which hangs over the case; but as soon as the tubercles soften, and become discharged through openings into the bronchial tubes, then the stethoscope will commonly be of use. According to Louis, who has written the best treatise upon this subject which has yet appeared, hoemoptysis occurred in two-thirds of his phthisical cases, and on many occasions it took place before the expectoration and the cough. He has been led to conclude, that a profuse hoemoptysis renders the existence of tubercles in the lungs very probable. This symptom showed itself more frequently in women than men, in the proportion of three to two. It is frequently difficult to say, whether the pain in the chest be owing to an affection of the muscles, or depends on the formation of tuber- cles in the lungs; in the latter stages there can be no doubt that it is produced by pleuritic inflammation, in the course of formation of ad- hesions, which are almost constantly found when a cavern is situated near the surface of the lung. Diarrhoea showed itself in all Louis's cases; and when I come to state the appearances on dissection, it will be seen that this symptom is produced by irritation and ulceration of the bowels. Sometimes the appetite is not at all impaired, even when diarrhoea prevails; at other times the appetite is bad and fastidious, with frequent attacks of nausea, and sometimes vomiting. Occasionally there is pain in the right hypochondriac region. The tongue presents various appear- ances; sometimes in the first part of the disease, it is perfectly clean and moist; at others loaded, exceedingly rough and cracked, with Vol. I.—55 434 PHTHISIS PULMONALIS. considerable redness at the edges; and in the last stage, when there are extensive ulcerations in the bowels, it has the same appearance as that already described in dysentery, viz., as if skinned perfectly raw, red and glazed. The lining membrane of the mouth and tongue is sometimes covered with aphthous ulcerations, which aggravate the patient's sufferings very considerably. Occasionally the epiglottis, pharynx, and oesophagus, are similarly affected, producing great thirst, and difficulty in swallowing fluids as well as solids. Appearances on dissection.—Bayle divided phthisis into nearly as many species as there have been diseased appearances found in the lungs; but Laennec and Louis, on the other hand, think there is only one species of phthysis—the tubercular. The latter author states, that he has not examined the body of one subject, without finding as the principal lesion, tubercles or tubercular excavations, or the demi-trans- parent gray granulations: he joins Laennec, therefore, in stating, that the existence of tubercles in the lungs is the cause, and constitutes the proper character of phthisis. Before describing the various morbid appearances found in subjects who have died of phthisis, I shall seize the opportunity of stating some particulars respecting those accidental formations which are called tubercular. They are bodies of a yellowish white colour, variable in consistence, which subsequently soften. When situated in the lungs they are sometimes expectorated by the bronchi, giving rise to ex- cavations more or less extensive. They are always more numerous, larger, and more advanced in their development, towards the supeior part of the lungs, than in the lower lobe. Out of one hundred and twenty-three dissections, Louis mentions having seen two exceptions only to this rule; for some years past I have seen one exception only, and in it the superior lobe was quite healthy. According to Laennec, tuberculous matter may be developed in the lungs under two forms, —insulated bodies, and interstitial injection or infiltration. He divides the insulated bodies into four kinds,—miliary, crude, granular, and encysted; the second has three varieties,—the irregular, the gray, and the yellow. Under any of these forms, the matter presents, in the early stage, a gray semi-transparent substance which gradually be- comes yellow, opaque, and dense; it afterwards softens, and gradually becomes converted into a fluid, like thick cream or pus, which being expelled through the bronchi, leaves cavities in the lungs, which were formerly termed ulcers. Miliary Tubercles.—This variety of tubercles is most common. The size varies from a millet to a hemp seed, very irregular in shape. Phthisis pulmonalis. 435 At first they are distinct, and afterwards become grouped together, and very often run into one another, so as to form one mass. A small yellowish opaque point appears near the centre of each tubercle, which gradually enlarges, till it involves the whole mass; it cuts like cheese, and constitutes the crude tubercle. Sometimes the miliary tubercles do not coalesce, but continue to the last distinct, and sometimes ac- quire considerable size. Sometimes distinct masses are seen, which are frequently the product of many tubercles united together. Granular Tubercles.—These were first described by Bayle, and were considered by him to be distinct from tubercles. But Laennec and Louis assert, that they are nothing more than the ordinary tu- bercle in its first stage. The former distinctly states, that the only difference between these granulations and the yellow tubercles, is that between green and ripe fruit; " besides (says he, at page 275,) the miliary granulations are never met with, except in lungs in which there exists at the same time other tubercles of a larger size, and suffi- ciently advanced to render their character no longer matter of ques- tion." My observations oblige me to dissent from this statement. Within the last six years, I have seen a considerable number of instan- ces in which granular tubercles pervaded the whole of both lungs; they were all nearly about the same size; the surrounding pulmonary tissue was of a red colour. Several drawings showing these appear- ances, are in my port-folio. In these cases, there was little cough, and very slight expectoration; and in one adult the lungs weighed nine pounds and three quarters. Three cases were children; in two of which tubercles were found on the arachnoid coat of the brain also; and in one, the membrane on one of the hemispheres was ulcerated in a great many points. This kind of tubercular formation in the lungs has long engaged my attention, and I feel convinced they are the air-cells distended and enlarged by a diseased deposition, proba- bly the consequence of inflammation of their inner membrane. A similar appearance may be produced by pouring a little quicksilver into the air-passages of a rabbit, if it be allowed to live for some days after the experiment. At one time I felt disposed to believe, that bronchitis was the cause of almost all tubercular formations in the lungs, which opinion appeared to be so far confirmed by a well known fact, that the majority of individuals who die of phthisis, attri- bute their illness to what they call a neglected cold: but I have been induced to abandon this opinion. Encysted Tubercles are rare. I have seen cases where one, two, or three encysted tubercles were found in the lungs, about the size of a 436 [phthisis pulmonalis.] filbert, inclosed in a cyst. Two of the cases died of hooping-cough, and another of the disease called tabes mesenterica. In all these cases the surrounding substance seemed somewhat firmer and redder in colour than usual, but in other respects there was no disease in the substance of the lungs. Laennec says they are rare, and Louis declares he has only seen one instance of this formation. On making a section of the tuberculous mass, it appears of a whitish colour, semi- transparent, and of a texture like hard cheese; but for a more minute account, I must refer to the works of the above authors. With respect to the tuberculous infiltration, I have to observe, that it is commonly of a grayish-white colour, sometimes with a rose tint, and is found either surrounding tuberculous excavations, or ex- isting in large masses, occupying the whole lobe of a lung, having no connection with the miliary tubercle; indeed, I have a preparation in which every part but the superior lobe is infiltrated with this matter, and 1 have an idea, that this may be one of the ultimate terminations of the agranular tubercle. This opinion is somewhat supported by Laennec's description of the gray tuberculous infiltration. According to Laennec, tubercles first show themselves in the top of the upper lobe, more particularly on the right side; while Louis states, that they are more frequently met with in the left lung. My own experience corroborates Laennec's statement. An important question is still undecided, and will perhaps remain so, as to the cause of this singular formation. Some insist that tuber- cles are the product of inflammation of a peculiar kind; while others, with as much confidence, allege that they have nothing whatever to do with inflammation, except in as much as they sometimes excite it by mechanical irritation. Dr. Baron maintains that tubercles are primitively hydatids; and although he has supported his doctrines with much learning and ingenuity, yet I feel persuaded he has not convinced a single pathologist. [Much observation and reflection devoted to this subject, have led me to adopt the following propositions: for the full elucidation of several of these, the profession is mainly indebted to the celebrated Andral: 1. Tubercular matter is a secretion from the blood vessels. 2. This secretion is a morbid condition of the albuminous halitus proper to the cellular tissue, forming the parenchyma of organs. 3. Inflammation is not necessary to its development, but may be either a cause or a consequence. 4. The cellular tissue which envelops and intersects tubercles, [phthisis pulmonalis.] 437 sooner or later takes on inflammation, and secretes pus; by which process the tubercular matter is eliminated and an abscess is formed. 5. The morbid state immediately antecedent to the tubercular secre- tion, and which may be considered its exciting cause, is a sanguineous congestion, analogous to that which precedes every secretory process. Physiology teaches us that in the healthy living body there is a constant secretion, from the blood, of an albuminous halitus, which is deposited in every part of the system, and in no structure so abun- dantly as the cellular tissue. Whatever deranges this interstitial se- cretion tends to the production of preternatural substances: hence any irritation may act as an exciting cause; not that it necessarily increases the activity of the secretory process (which in health in very prolific) but because it perverts this important function. Such appears to have been the opinion of the indefatigable Baumes, who in his work read before the Medical Society of Paris, in 1783, holds the following language: "An organ that has become enfeebled, secretes its peculiar fluid in an imperfect manner: these fluids no lon- ger possess the degree of vitality necessary to stimulate and support the solids: they become from day to day more unnatural, until at length they cease to have any analogy with healthy structure." De la Phthisie, v. i. p. 135. Analysis has proved tubercular matter to consist almost entirely of albumen, showing its affinity, in this respect, to the healthy interstitial secretion, from which it mainly differs in certain physical characters. The reason why the tubercular secretion is so much more common and abundant in the lungs than in other structures, is, that the former are composed of a most delicate series of tissues, which are pre-emi- nently exposed to the many vicissitudes arising from atmospheric changes, inordinate physical exertions, and direct mechanical irritation. Tubercular disease is by many considered to be invariably a product of inflammation: but although the latter often accompanies it, and always in its second stage, it appears to be by no means essential to its secretion, any more than to the deposit of osseous particles in the coats of an artery, or in the substance of a cartilage. Tubercles are often found in great numbers in the lungs after death, without their having been even suspected during life; and if these tubercles have not passed to the crude state, the parenchyma around them is often found perfectly healthy, presenting, in fact, no trace of pneumonia. Could the pulmonary tissue maintain this integrity if each tubercle was a centre of inflammatory action? It appears to me that inflammation is much oftener a consequence than a cause of tu- 438 [phthisis pulmonalis.] bercles; the latter forming independently of it, and subsequently in- ducing phlogosis like any other extraneous bodies. Thus it is that tubercles induce pneumonia; while, on the other hand, pneumonia is a cause of tubercles: for I conceive it to be inconsistent with analogy as well as with fact, to restrict this secretory process to an inflamma- tory state of the vessels, and vice versa. This exclusive doctrine (to which I was at one time strongly biassed) has given rise among pa- thologists to those conflicting views, which can only be reconciled by a concession like that here admitted, and which is founded on the known phenomena of diseased action. The theory of the lymphatic origin of tubercles, which is now so generally received, is at least as old as Sylvius, (1671,) who supposed the lungs to contain an infinite number of minute conglobate glands, analogous to those of the mesentery. This opinion has been ampli- fied with great ingenuity by M. Broussiais, who attributes tubercular matter to an inflammation of the lymphatic glands and vessels conse- quent to inflammation of the sanguiferous capillaries; in fact, a double inflammation,heginning in one set of vessels and thence propagated to another. Without entering into a discussion of this question, I will merely observe, that if tubercles originate solely in lymphatic glands and vessels, ought we not more frequently to meet with them where these structures are most abundantly distributed,as in the axilla and groin, the mesentery, neck, &c? Yet it often happens that in persons who have died of phthisis, we see the bronchial, axillary, and inguinal glands greatly tumefied and diseased, without being at all tuberculous; while on the other hand we find the same hypertrophy, and disease of the bronchial glands, in those pulmonary affections in which tubercles have had no part. This hypothesis presupposes the existence of innumerable minute glands in the lungs; but anatomy, even aided by the microscope, has never detected them: moreover, a true tubercle has not the anatomi- cal characters of a gland; for it is closely attached, to the surrounding parenchyma; whereas all glands, especially when enlarged by disease, possess their proper capsules, which enable them to be dissected out with facility.] The body of a person who has fallen a victim to this very dreadful disease, is found greatly emaciated, sometimes to the last degree, and the chest looks contracted on itself, which may, however, be a decep- tion produced by the general emaciation. But Laennec thinks the contraction of the chest is real, and is to be attributed to two causes: phthisis pulmonalis. 439 1*/, To the existence of pleurisies, to which phthisical patients are extremely liable. 2dly, To the attempts made by nature to cure phthisis. On opening the thorax, the heart is sometimes observed to be small; Laennec says, it is almost always remarkably so. The lungs are sometimes found adhering, throughout their whole extent, to the ribs; and the left lung is frequently attached to the pericardium, which is occasionally distended with serum. Sometimes one side of the thorax contains a puriform matter, with a considerable quantity of air, the result of a vomica bursting into the cavity, leaving a commu- nication open with the bronchial tubes; when this is discovered, the person is said to be affected with pneumo-thorax, which may be as- certained by the splashing noise which is heard, when the patient's body is shaken by the shoulders; the stethoscope communicates a peculiar sound, called the metallic tinkling. The powers of the con- stitution, however, employed to prevent this accident, are generally successful, by effusion of lymph, and the agglutination of parts. These adhesions are mostly found at the superior lobes, and sometimes are so dense, that it is impossible to separate them with the fingers, without tearing the lung itself. On removing the lungs from the body, they are found to be much heavier than natural; one case I have already mentioned, in which they weighed nine pounds and three quarters. Notwithstanding the assertion of Laennec to the contrary, it has occurred to me several times to see the marks of the ribs left upon the posterior and lateral parts of the lungs, when they were very heavy;* I have seen it in two cases, where one lung was extremely dense and large, the effect of long-protracted chronic peripneumony. On making a longitudinal section of the lungs, which will usually be found " to cry under the knife," we sometimes find one excavation only, which may be full, none of the contents having yet found their way into the bronchial tubes; and when solitary, it is almost always in the superior lobe. In general, however, many cavities are found, more or less filled with softened tuberculous matter, and the most striking difference will be observed in the progress of the tubercles in different situations, being commonly farthest advanced in the supe- rior parts; occasionally they present the appearance of fresh crops. Sometimes the lung is found studded with miliary tubercles, affecting the pleura also, and most commonly some of the bronchial glands will be found enlarged and hard, sometimes melanotic. I have met [* I have also met with a solitary example of this kind.]—Ed. 440 phthisis pulmonalis. with this condition of the lungs only twice or thrice in children. I have seen several dissections in which the tubercles, called granular by Bayle, were found in immense numbers, dispersed with great re- gularity throughout the whole substance of the lungs, with interven- ing spaces of a red colour, having the appearance of the roe of a salmon. Occasionally we find a chain of excavations extending throughout the whole lung, communicating with each other; the tubercles having become successively softened, and then discharged. In these exca- vations, bands are seen stretching in every direction, like the fleshy columns in the ventricles of the heart, which seem to be composed of condensed pulmonary tissue, coated over with tuberculous matter, or, as it has occasionally appeared to me, coagulable lymph; these bands sometimes contain blood-vessels. Bayle makes the same remark, which is questioned, however, by Laennec, who states that he has " never even found a vessel of any consequence included within the substance of these bands;" but I have had several opportunities of demonstrating it to my class. Indeed, on one occasion a large blood- vessel in one of these bands gave way, and the child quickly died. This is the case noticed at page 241, and in which the blood found its way from the cavern by a fistulous opening into the oesophagus, as high up in the neck as to correspond to the inferior margin of the thyroid gland, and from thence passed into the stomach. It will be remarked that Laennec's expression is qualified, and I am ready to grant, that it is rare to find vessels of " any consequence" in these bands, because they must be compressed and diminished in size, in proportion to the condensation of the pulmonary tissue in which they are involved. Laennec supposes, that the tubercles, during their in- crease, separate the blood-vessels, and press them to one side, which would no doubt hold good, if there were only one mass; but it is not a satisfactory explanation of the situation of the blood-vessels, when the lungs are completely studded with tubercles. On one occasion, I found the blood-vessel passing through a cavern, in one of the bands already described, which had become obliterated by a plug of coagu- lable lymph. The ramifications of the bronchi seem to be obliterated; they are frequently found to open into a cavern, but I have never seen a trace of them in the tuberculous matter. In proportion as the tubercle be- comes softened and discharged, the walls of the excavation are found more or less thickly covered with something like a membrane, which can be scraped off with the knife. According to Laennec, this mem- phthisis pulmonalis. 441 brane presents in different parts of its surface projecting points. Some- times there is an appearance of two membranes, but occasionally the walls of the cavity are formed by the natural tissue of the lung itself, condensed, red, and charged with tuberculous matter. Sometimes the walls of the caverns appear to be lined by a membrane of fibro- cartilaginous consistence, occasionally filling up a small cavern en- tirely, presenting an appearance of cicatrization; in this way it is supposed that phthisis is sometimes cured. The mucous membrane of the bronchial tubes is generally red and thickened; that portion of it which lines the trachea and larynx, is occasionally red, thickened, and pulpy, with ulcerations here and there. Ulcerations are sometimes seen as far down the tubes as the third and fourth division. Occasionally the epiglottis and larynx are also covered with numerous ulcerations, sometimes having the ap- pearance of chancres. > The stomach occasionally presents diseased appearances, its mucous membrane being sometimes red, thickened, and velvety, with dark streaks, as if seared with a red-hot iron. In other cases, a great por- tion of the mucous membrane is found entirely removed, generally from the splenic extremity, leaving the naked vessels exposed, the rest of the membrane being thickened, soft, and reddish, with a great number of redder spots in the neighbourhood of the parts already de- stroyed, as if a pen-full of red ink had been spattered over the surface. Sometimes large red vessels are seen arborescing in the mucous mem- brane, which displays appearances here and there, as if portions had been removed by passing the nails roughly over the surface of the stomach. In one case, all the coats of the stomach except the peri- toneal, were destroyed over a space about the size of a shilling, but of an oval shape. In very few cases has it occurred to me to see tuber- cles in the mucous membrane of the stomach; they are frequently seen in that of the intestines, particularly in the caput caecum, ascend- ing colon, and termination of the ileum; they are sometimes situated in the mucous coat, and at others in the sub-mucous tissue. It is pre- cisely in the situation above described that ulcerations are most fre- quently found, occasionally involving the whole of the colon down to the sigmoid flexure, which is much thickened in its texture, in some cases feeling contracted and hard like a small rope. The state of the mucous membrane has been so often described in this work, that I have only one additional observation to make, which is, that I have never seen the ulcerations undergoing the healing process in the dis- ease now under consideration; nor the mucous surface in that dark, Vol. L—56 442 PHTHISIS PULMONALIS. livid, fleshy, and thickened state, which it frequently shows in dysen- tery. The peritoneum is sometimes found inflamed, thickened, and covered with flakes of lymph, which may be traced to points of the intestines, at which the ulcerations have extended through the other tissues, till it attacked the peritoneum itself; occasionally, indeed, a small perforation is found, which has admitted the passage of fecu- lent matter into the cavity of the abdomen. The peritoneum is fre- quently the seat of tubercles. They first appear perhaps in the mili- ary form, and afterwards become crude. The mesenteric glands are always found enlarged and altered in structure in phthisis, when the bowels are affected. The liver is sometimes found diseased, more frequently perhaps in women than in men; it is generally softened, enlarged, and of a whitish or yellow- ish colour, feeling greasy to the touch. This is the fatty liver; I have seen it so large as to fill the iliac region, the right lobe extending down to the brim of the pelvis. The spleen is sometimes found tuberculated both in its substance and its capsule. The omentum is occasionally diseased in phthisical subjects. It is found thickened; fatty like the liver, and tuberculated. The brain is found in various states; sometimes there is effusion between the arachnoid in pia mater, or into the ventricles, the effect, in all probability, of impeded circulation. Tubercles are also ob- served in various situations in the brain, and in different stages, either solitary in some part of the cerebral substance, or spread generally over the arachnoid membrane, where I have seen them frequently in the miliary form, as well as in a crude state. It has never been satisfactorily explained, why ulcerations should be found so frequently in the mucous membrane of the bowels in phthisis. It may, perhaps, be partly attributed to the obstructed state of the circulation, producing considerable vascular distension in its vessels, which at last become inflamed and ulcerated. There may be also something in the diseased condition of the blood itself, which cannot be perfectly de-carbonized. I have little doubt that the mu- cous surface of the bowels, in the ordinary state of the system, assists the lungs in depriving the blood of carbon. After they have been impeded, by the tubercular state of the pulmonary substance, perhaps the mucous surface of the bowels becomes more active, thereby caus- ing inflammation and ulceration. There is no doubt that ulcerations in the intestine are sometimes owing to the irritation of tubercles in the part; but this speaks for itself. For further particulars relating to the morbid appearances found in this disease, the reader is referred to the work of M. Louis. [PHTHISIS PULMONALIS.] 443 [Causes.—Consumption is a remarkable instance of hereditary dis- ease: thus when the parents have died of constitutional phthisis, the children are almost sure to suffer. This predisposition, or tuberculous diathesis, is not confined to any period of life, but is most apt to show itself between the ages of eighteen and thirty-five years. Some authors have endeavoured to identify it with the scrofulous habit, from which, however, it appears to be entirely distinct; scrofula is most active in the juvenile state, while phthisis is a disease of adult age. I have twice seen the scrofulous diathesis developed in the spine even to de- formity, and accompanied by chronic pulmonary disease, without ex- citing a tubercle in either lung. The physical characteristics of scro- fula and phthisis are not the same; for two thirds of the consumptive patients who have come under my care have had dark hair, dark or sallow complexions, and dark eyes. It seems, indeed, extremely dif- ficult to detect the tuberculous constitution by any physical appear- ances of even general application; and still more difficult to identify it with the scrofulous diathesis. If the predisposition to phthisis exists, various slight causes are suf- ficient to excite it into action. Thus bronchitis, pneumonia, haemor- rhages, the depressing passions and exhausting indulgences, bad diet, sedentary occupations, and a hundred other means by which the healthy functions of the system become perverted, may be adduced as exciting causes.] Treatment.—Although Laennec states that phthisis is curable, still such a happy event is scarcely to be expected after the disease is formed, and it is very possible he may have been mistaken. The only case which I conceive to be capable of a spontaneous cure, is that in which a solitary tubercle has existed, without any other dis- ease of structure in the lungs. Much may, however, be done in ward- ing off the disease for many years, and retarding its progress after it is formed, by care and management of an individual,—by attending to his diet, which should be nourishing and moderate,—to his cloth- ing, which should be warm and light,—and to his exercise, which should never be carried the length of producing fatigue. Constipa- tion should be avoided, and 6uch an individual should remove to a steady climate if he can afford it. After the disease is somewhat ad- vanced, a great deal of expense and trouble may be spared by keep- ing the patient at home, because, at this period, change of climate will do no good; on the contrary, I have known it frequently to hasten the fatal termination, from fatigue and accidental exposure to cold during the journey. 444 [phthisis pulmonalis.] [When I meet with a case of phthisis that is just developing itself, when the disease is confined to one lung and is circumscribed in ex- tent, and the patient's general health not yet impaired, 1 pursue the following plan. 1 at once establish an issue of caustic potash over the diseased part, and keep it discharging by means of basilicon, savin, and mezereon, and by washing it with soap and water. The cough should be controlled through the day by demulcent and acidulated drinks; but at bed time, if it continue troublesome, I direct as much anodyne as will secure the patient a night's rest. In this manner the cough will be chiefly confined to the early part of the day, when the patient is best able to bear it. If there be febricula, with a frequent pulse, I am partial to the use of digitalis, which sometimes has a most happy eflect in reducing the wearing excitement of the blood vessels. To this simple treatment I add the internal use of the preparations of iodine,—the most powerful alterative, with the exception of mercury, with which we are acquainted. I give them for about a week at a time, then omit them for a like period, and thus alternately discon- tinue and resume them. The patient's diet should be light but nutri- tious, using freely of the farinaceous articles, and avoiding every in- digestible article of food. Conjoined with these means I direct daily free exercise in the open air by walking, riding or driving, and by protracted journeys, when these can be resorted to without undue fatigue or exposure. As an interlude I am extremely partial to a sea voyage, particularly when it can be directed to a mild and equable climate. It is by a persistence in this plan of treatment, that I have now the satisfaction of seeing a considerable number of patients pur- suing their daily avocations, and enjoying a good degree of general health, whom I am confident never would have survived, for three months, the old practice of close confinement, low diet, antiphlogistics and mercurials. I do not pretend that in all such cases the tubercular disease is eradicated, or the abscesses cicatrized; but I know that the malady may be kept at bay, and rendered comparatively inert, until at length it ceases to molest the patient. The obliteration of abscesses by cicatrices is a very common occur- rence; but most unfortunately these cavities are seldom single or iso- lated, but on the contrary succeed each other at uncertain intervals, and thus keep up an exhausting drain on the constitution. But the existence of abscess does not prevent my pursuing the practice above mentioned, provided the general strength of the patient continues in a reasonable degree unimpaired. Abscesses may con- tinue for years, occasioning no pain, and little inconvenience beyond [phthisis pulmonalis.] 445 debility, more or less cough, and occasional febricula. Such instances, however, are exceptions to a rule; for where suppuration has taken place we have little to hope for.] Much may also be done to retard the advancement of the disease, to mitigate the patient's sufferings, and to smoothe his passage into the vale of death, by avoiding every cause which can hurry the cir- culation and respiration, and preventing exposure in bad or changeable weather. Phthisical patients suffer occasionally, very severely, from pains in the chest, produced by pleuritic inflammation, traces of which are almost always seen on dissection. Leeching and counter-irritation should therefore be occasionally employed. Profuse perspirations are to be discouraged, as is also the exhibition of acids, which are so often gfven to prevent them.* The bowels are to be assiduously at- tended to, so as to prevent constipation, and the necessity of having recourse to strong purgatives, particularly when the disease is of long standing; when a laxative is necessary, it should be of the mildest description, and united perhaps with the extract of hyosciamus. [This condition of the bowels may be, in a great measure, prevented by diet: thus, instead of bread made of wheat flour, the patient should be re- stricted to bran bread, conjoined with a free use of cream; sound ripe fruits, and the dried fruits stewed, subserve the same purpose.] When- ever a patient has more than the usual number of stools, particularly if they are watery, dark-coloured, and fetid, and when he begins to feel even slight uneasiness in the belly before going to stool, a few leeches should be applied to the abdomen, followed or not, according to cir- cumstances, by the application of tartar-emetic ointment to produce irritation. It is wonderful, in many cases, to observe the good effects which follow the application of leeches in subduing the inflammation of the mucous membrane, thereby controlling the diarrhoea, and pre- venting the formation of ulcerations. Indeed, I have seen the best * [I confess I cannot join in the author's hostility to mineral acids. The nightly recurrence of profuse sweats is so debilitating, and at the same time so distressing to the patient, that a physician is sometimes compelled to resort to some measure that will afford relief, even though it be merely temporary. Thus I have many times seen eight or ten drops of elixir of vitriol, given in a little cold water or bitter infusion at bed time, produce the happiest effects. A similar result may be obtained from a solution of alum in spirits, with which the limbs should be freely sponged. The infusion of sage may be taken internally for the same purpose. I use these means to check colliquative perspiration on the same principle that I would check a he- morrhage: either is exhausting to the patient; and where our curative means end, our palliative ones must begin. The same remarks will apply to the diarrhoea of phthisis.]—Ed. 446 PHTHISIS PULMONALIS. effects follow the application of leeches, even after a large extent of the mucous surface was ulcerated; but counter-irritation, produced sometimes by a mustard plaster, sometimes by hot spirits of turpen- tine, or by the antimony ointment, will be often found of essential service, when the patient is too weak to bear bleeding. [The Moors of Africa, among whom consumption is common, have a practice of controlling diarrhoea by means of two grains and a half of alum, with an equal portion of sulphate of iron, given in a powder. Having mentioned this plan to Dr. Pitcher of the United States Army, he subsequently informed me, that he put it in practice on two soldiers, who appeared to be dying with diarrhoea consequent to phthisis, and that both men were so .greatly relieved, as to be able in a short time to resame their duties in the garrison. I mention these facts with me more satisfaction, because I believe patients are sometimes allowed to die of diarrhoea, from an impression that it is a mere sequel of the pulmonary affection, and therefore incurable. I am decidedly of opinion that we should combat the diarrhoea with every available means, both internal and external, to the last hour of life. It is now upwards of two years and a half since I had in charge a middle aged man with an abscess in his left lung, which was soon followed by an exhausting diarrhoea; the latter was happily checked by strong opiate and astringent medicines, at the very time when the case appeared hopeless: the diarrhoea sub- sequently recurred twice, and was in like manner subdued, after which the patient's general health began to improve, and he is at the present time able to take daily exercise in the open air, although he still la- bours under his pulmonary disease, and is occasionally confined with relapses of various kinds.] Peritonitis is sometimes occasioned by an extension of the ulceration to the peritoneum; therefore leeches and counter-irritation are sometimes adviseable. An occasional opiate is also serviceable; and I have seen the best effects produced by the exhibition of one-twelfth of a grain of strichnine, when the bowel complaint was very troublesome. The duration of phthisis is very various; few survive above a year; indeed the generality of patients sink in about nine or ten months, and I have often observed that women die quicker than men. One case terminated fatally in about twenty days, where there was no other perceptible organic lesion, except the granular tubercles which affected every part of both lungs. Louis says he has seen a case fatal in twen- ty-four days, but that the^general period in acute phthisis is about fifty days. It was formerly mentioned, that Bayle divided phthisis into as many PHTHISIS PULMONALIS. 447 species as there have been diseased appearances found in the lungs. He has therefore treated of calculous concretions, under this title; to- gether with the condition which has been called melanotic; and that which has been so well described by Laennec, under the term " me- dullary cancer." It appears to me that Bayle was so far right, because when the lungs are thus affected, the individuals frequently emaciate, cough, and breathe in the same manner as in the tubercular disease. The following account of the more rare varieties of structural de- rangement found in the lungs, is compiled from Laennec's work:— 1st, Bodies of a cartilaginous, bony, calculous, and chalky na- ture.—Sometimes cartilaginous cysts are seen, containing bony or chalky concretions. Laennec states that the bony matter is not perfect, containing a greater quantity of calcareous phosphate, and much less gelatine than true bone, and hence these bodies resemble a piece of stone more than bone. In some cases, he says they contain no gelatine, and resemble moistened chalk. There are also found points of ossification in various parts of the lungs. I have never seen them provided with cysts, which Laennec states are very rare indeed; the non-encysted os- sifications are those to which I now allude. They are sometimes very numerous; they feel rough and pointed, and are generally adherent to the pulmonary tissue, which is sometimes of a cartalaginous hard- ness. Lately I dissected a lung studded over with this kind of pro- duction; each was surrounded by a melanotic mass, which, when situ- ated on the surface of the lung, adhered to the pleura in such a man- ner as to prevent a separation. Sometimes they are observed in the bronchial glands. The chalky concretions are found in two states, one resembling soft chalk, the other like common mortar. In general, these are encysted. Sometimes calculous bodies, of the shape and size of small peas, are not only found on the surface of the lungs, but are also occasionally expectorated, which leads many to suspect that they are formed in the bronchial tubes: it is more probable they are formed in the substance of the lungs, and find their way into the air-passages by ulceration or absorption. When meeting with these large bodies on dissection, 1 have always seen considerable disease in the surrounding pulmonary tissue, sometimes in the state of recent inflammation, at others of gray or red hardening. I cannot sanction the opinion, that these concre- tions are the product of powdery substances taken into the lungs, sus- pended in the air we breathe; but bronchitis is often produced in this manner. Laennec supports the same opinion, and his reasoning ap- pears to be quite conclusive, (p. 380.) He believes that these con- 448 MELANOSIS. cretions are consequent to tuberculous affections that have been cured; but I see no reason for agreeing with him in this opinion. 2d, Melanosis of the Lungs.—These productions, in their early or crude state, " possess a consistence equal to that of the lymphatic glands, and a homogenous and somewhat humid composition; they are opaque, and in structure very much resemble the bronchial glands in the adult. When they begin to soften, a minute portion of fluid can be expressed from them, of a thin reddish character, intermixed with small blackish portions of a substance which is sometimes firm, sometimes friable, but which, even when friable, conveys to the touch an impression of flaccidity; in a more advanced stage, these portions first, and subsequently the whole mass in which they are contained, become quite friable, and are soon converted into a black paste. Me- lanotic matter is found in four different forms, encysted, non-encysted, generally infiltrated into the natural texture, and deposited on the sur- face of organs." (Page 383.) Encysted Melanosis.—" The cysts enclosing this species are very regularly rounded, and vary in size from that of a small hazle-nut to that of a walnut. They have a very regular and equal thickness, which is never greater than half a line. Cellular substance appears to be the only tissue that enters into their composition. They adhere by means of a very fine cellular membrane to the substance of the organ in which they are situated, and from "which they can be readily separated by dissection. Their interior surface is rather smooth, but adheres to the morbid matter which it surrounds. The medium of this adhesion appears to be a very fine imperfect cellular tissue, though it cannot always be distinguished. I have hitherto (says he) only found this variety of melanosis in the liver and lungs; and in the lat- ter organ I have only as yet met with a single mass of it." (Page 383.) Unencysted Melanosis.—" This variety is much less rare than the preceding. 1 have met with it (he says) in the lungs, the liver, the pituitary gland, and the nerves; but it has been since found in almost every organ. The volume of masses of this kind is quite indetermi- nate, varying from that of a millet seed to that of an egg, or more. They are also quite irregular in figure. They commonly adhere very closely to the parts in which they are situated; sometimes, however, they are united to these by a very fine, though sufficiently visible, cel- lular tissue, which permits their removal without any laceration. In this last case they are commonly of a rounded shape." (Page 384.) Melanotic matter generally infiltrated into the natural texture., —'• It frequently happens that this morbid matter, in place of being MELANOSIS. 449 segregated in distinct masses, is disseminated throughout the organs in which it is found, and deposited between the particles or molecu- les of the natural tissue. The appearance and colour of parts affected in this manner, present a good many varieties, according to the texture of the organ, the quantity of matter deposited, and the particular con- dition of this matter. When the infiltration is recent, and in mode- rate quantity, the appearance of the affected part merely differs from the natural condition, in being intermixed with small black dots or striae, the intermediate portions being quite -of a healthy character. As the disease increases, the dots and striae enlarge in number and volume, until the whole of the natural tissue of the part is lost in the morbid degeneration. It is usually only at this period of its progress that the melanosed matter begins to soften: but if the softening takes place before the complete removal of the natural tissue of the part, it frequently happens that this softens also, and intermingles with the morbid matter, the colour of which is thereby changed to brownish, yellowish or grayish." (Page 384.) There are various preparations in my museum, which illustrate these very excellent descriptions of M. Laennec. There is one, showing the last variety of this affection, which was found in the stomach of a dram-drinker. I have also the portion ofa lung, the whole of which was affected with the disease, and which looks like a sponge filled with very black ink. There is also a rare spe- cimen of melanosis affecting the pleura pulmonalis. A case, rapidly fatal, occurred to me in 1825. The subject was a middle aged man, who began to complain on the 15th July, but did not take medical advice till the 19th, when he was found to complain of severe pain and weight in his head, some ringing in his ears, but no intolerance of light; the pain was increased by motion and cough- ing; his breathing somewhat accelerated; respiration 24 in a minute; but he had neither pain, cough, nor expectoration; complained of un- easiness in the abdomen, which was not increased on pressure; tongue whitish in the centre, and at the edges red; skin hot and dry; pulse 90, full and strong. Twenty ounces of blood were taken without any decided relief, and in five hours afterwards, twelve ounces more, which removed the headache. On the 20th, he was so much better as to be able to leave his bed, but became worse again towards even- ing. 21st, Again somewhat improved. By the stethoscope, the respiration was noisy and blowy, which led to a suspicion of the ex- istence of crude tubercles, surrounded by healthy structure; respira- tion 30; pulse 112; tongue not improved; face somewhat flushed; Vol. I.—57 450 MEDULLARY SARCOMA. i 1 skin hot and dry. He died next morning in what his friends called "a fit," which appeared to be asphyxia. The lungs were found completely infiltrated with melanotic matter, but still crepitating; and they floated when placed in water; the spleen was affected in the same manner.' 3d, Medullary Sarcoma.—According to Laennec, "medullary sarcoma may exist under three different forms, viz., 1st, encysted; 2d, in irregular masses without a cyst; and 3d, diffused in the tissue of an organ. In whichever of these forms it exists, it presents, in its progress, three different and distinct stages, viz., 1*/, the incipient or crude state; 2d, its perfect state, in which it exhibits the resemblance to brain, which forms its special characteristic; and 3d, its soft or dissolved state. "I shall first describe it as it is observed in the second or perfect state, as this is the condition in which the three varieties most nearly resemble each other, there being much difference between them in the first and last stages. In its perfect state it is homogeneous, of a milky whiteness, and very like the substance of the brain. In different parts it has commonly a sight rose tint. It is opaque when examined in mass, but in thin slices it is in a slight degree semi-transparent. Its consistence is like that of the human brain; but it is commonly less coherent, being more easily broken and comminuted by the finger. According to its degrees of density, it resembles one part of the brain more than another; but it is more commonly like the medullary sub- stance of a brain that is more than ordinary soft, (or like that of a child's,) than the healthy brain. When existing in any considerable extent, this species of cancer is, in general, supplied by a great many blood-vessels, the trunks of which ramify on the exterior of the tumours, or between their lobes only, while the minuter branches penetrate their substance. The coats of these vessels are very fine, and readily ruptured; and this accident gives rise to clots of extravasated [« In the splendid work of.Dr. Carswell, "Illustrations of the elementary forms of disease," the reader will find an admirable view of every form and variety of melanosis. On the present occasion I shall merely quote one or two facts respect- ing the chemical characters of true melanosis, which Dr. Carswell, however, calls melanoma. Melanotic matter is essentially composed of the colourino- matter of the blood, united with fibrine, (both of them in a particular state,) three kinds of fatty matter, and a considerable quantity of phosphate of lime and iron. I am inclined to believe that melanosis is of less frequent occurrence in the United States than in Europe. In my dissections it has occurred with extreme rarity.]—En. MEDULLARY SARCOMA. 451 blood in the interior of the tumours, sometimes of considerable size, which bear occasionally a striking resemblance to those found in the brain of subjects dead of apoplexy. Extravasations of this kind may sometimes be so considerable as to supplant almost the whole of the brain-like matter, so that the true nature of the tumour can only be ascertained by some small points, still remaining, of the original growth. This change occurring iir superficial tumours of this kind, and being productive of much haemorrhage, appears to me to have given rise to the name of fungus haemafodes, applied to certain can- cers by modern surgeons. Under this name, however, I am also con- vinced that they have confounded tumours of different kinds, especi- ally those commonly called varicose, which are composed of an acci- dental tissue, very analogous to that of the corpus cavernosum penis. I have never observed any lymphatics in tumours of this sort, but it is probable that the circulating system is complete in them, as I have seen their substance deeply tinged with yellow in cases of icterus. The matter of encephaloid does not continue long in the state just de- scribed; it tends incessantly towards a softer condition, and, in a short space, its consistence scarcely equals that of a thickish paste. Then be- gins the last stage; the process of softening becomes more rapid, until the morbid matter becomes as liquid as thick pus, still, however, re- taining its whitish or rosy white tint. Sometimes at this period, or a little earlier, the blood extravasated from the vessels contained in the tumour, becomes intermixed with the morbid matter, so as to give it a dark red colour, and the resemblance of clots of pure blood. In a T short time the extravasated blood is decomposed; the fibrin concretes, and, together with the colouring matter, unites with the brain-like matter of the tumour; and the serum is absorbed. In this condition the morbid growth retains no resemblance to brain; it is of a reddish or blackish colour, and of a consistence like that of paste, somewhat dry and friable. Sometimes the change of structure and appearance is so complete, that one would be led to consider the tumours as of a different kind, but for the existence in them of portions of the original matter still unchanged. In some cases, contemporaneously with tu- mours that have been changed in this manner, there will be found others retaining the original cerebral character; so that, in all cases, we are able, with a little practice, to discover the true nature of the tumour in all its stages." (Forbes' Translation, p. 393.) " Such are the characters which this species of cancer presents in its two latter stages, and equally in all the three varieties. I shall now describe the characters of each of these varieties in the first or crude state. 452 MEDULLARY SARCOMA. " 1. Encysted Medullary Sarcoma.—The size of this species is very various. I have seen the tumours as small as a hazle nut, and larger than a middle-sized apple. I have found them as large as this in the lungs. The cysts are of pretty equable thickness; and this is never more than half a line. They are of a grayish-white, silvery, or milky colour, and have a semi-transparency, more or less, ac- cording to their thickness. Their texture is altogether cartilaginous, and rarely fibrous; but it is much softer, and less easily broken by bending than cartilage; on this account they must be ranged among the imperfect cartilages. The medullary matter contained in these cysts, can be easily detached from their inner coat. It is commonly divided into several lobes, by a very fine cellular tissue, which may be compared with the pia mater, and the more so from the great number of blood-vessels which traverse it. The fineness and brittleness of these have been already noticed, and also their penetration of the cere- briform matter itself, to which they give a rose tint here and there. It is their rupture that gives rise to the clots of blood formerly men- tioned. Sometimes, also, the trunks of these vessels are ruptured in the interstices of the lobules; and the blood being injected beneath the fine cellular substance which accompanies them, gives this the appearance of a distinct membrane. It is commonly in their early or crude stage that these tumours are divided into distinct lobes. These are especially observable on their surfaces, and have sometimes con- siderable resemblance to the convolutions of the brain. The cyst does not at all enter between these convolutions, nor does it even in- dicate on its surface their place or configuration. In this stage the medullary matter is pretty firm, often firmer than the fat of bacon. It is of a dull white, pearl gray, or even yellowish colour, and in thin slices, has a slight degree of semi-transparency. When cut into, it appears subdivided interiorly into lobules, much smaller than those seen on its surface. These lobules are in such close contact as to leave no interval whatever; and their separation is merely indicated by the reddish lines traced by the vascular cellular tissue, by which the sepa- ration is affected. These lines rarely cross each other, but exhibit many irregular curves and convolutions. When these tumours pass into the second stage, their texture becomes more homogeneous, and all distinction of the small interior lobules is quite lost; the distinction, however, of the larger exterior lobes still continues. The blood-ves- sels which run between these lobes, and in the cellular tissue imme- diately investing the tumour, are much more developed than in the early stages of the disease, and it is only at this second stage, or as it approaches the third, that the extravasations of blood take place. MEDULLARY SARCO.MA. 453 The third stage begins, as I have already mentioned, when the me- dullary matter has acquired a consistence like pap or paste, or like that of a brain softened by commencing putrefaction. In this state, it has still much resemblance to cerebral substance. I have never found that the morbid growth ever softens still more, or that it is ab- sorbed or evacuated, so as to leave an empty cyst, or cavity like tu- bercles; consequently it is not probable that we shall ever find pec- toriloquism as a sign of this affection. Hitherto I have only found these encysted medullary tumours in the lungs, liver, and cellular sub- stance of the mediastinum." (Page 395.) " 2. Unencysted Medullary Sarcoma.—Medullary tumours of this species are very frequently met with. Their size is very variable. I have seen them from the size of the head of a full grown foetus to that of a hemp seed. Their shape is commonly spheroid, but occa- sionally flattened, ovoid, or altogether irregular. Their external sur- face is lobulated, but the divisions are less regular than in the encysted species; their internal structure, in the two last stages is precisely the same. The cellular membrane which invests them, is more or less marked, according as they are placed in a loose cellular tissue, or in the substance of a viscus of firm texture; in the latter case, their in- vesting membrane is thinner and less distinct. In their first or crude stage, their semi-transparency is greater than afterwards; they are almost colourless, or have a very slight blueish tint in ocellated patches; they are pretty hard, and divided into numerous lobes. Their substance is then fatty, like lard; but when incised, it does not at all grease the scalpel, and it coagulates by heat, without showing a particle of fat. The transition from the first to the second stage takes place in the following manner:—The substance of the tumour be- comes more opaque, softer, whiter, and its inner distinction into lo- bules, for the most part, disappears. The original texture is observed longest in the neighbourhood of the external interlobular fissures. In this situation, I have found portions still in a state of induration, after the mass of the tumours had passed into the third stage. I am led to conclude that the encysted tumour follows precisely the same pro- gress as that just described. The non-encysted medullary tumours may exist in any part of the body; but they are most frequently met with in the loose and abundant cellular tissue of the limbs, and in the larger internal cavities. I have met with them in the cellular mem- brane of the fore-arm, thigh, neck, and mediastinum; they are still more frequently found in the cellular substance around the kidneys, and the anterior part of the spine, and in these situations they often 454 MEDULLARY SARCOMA. have a very large size. Although they are frequently found in the viscera, they are, however, much rarer there than in the cellular sub- stance." (Page 397.) In my collection there are several fine specimens of these varieties of medullary sarcoma, and others unnoticed by any author, but which it^would be tedious to describe. CHAPTER VII. ASTHMA. This term was formerly used to express every species of difficulty of breathing, but latterly it has been employed to signify a specific intermittent dyspnoea, independently of organic lesion; but I shall show how erroneous are such views of this disease, when I come to treat of its pathology. This disease is observed, most frequently, in people beyond the middle age, rarely in youth; it affects men oftener than women, and those of full habit of body more frequently than the spare; and it would seem to be occasionally hereditary. Phenomena.—Attacks of asthma sometimes appear towards the afternoon, or at the moment the patient is going to bed, but more fre- quently they occur during the night; occasionally, indeed, the patient is seized during a sound sleep, and awakes with a sense of suffocation, In describing the disease, I shall confine myself to a few of the lead- ing symptoms, because, depending upon so many morbid conditions of the lungs, heart, and perhaps the brain, the symptoms which may take place, have too wide a range of character to be taken into a short general sketch. Upon the approach of the paroxysm, the patient usu- ally feels a sense of coldness over the surface of the body, indeed sometimes severe rigors take place; instantly a constricted feeling is experienced in the chest, and difficulty of breathing,both of which are increased in the recumbent posture. He sits up, because he can then breathe more easily; he demands more air to be admitted into the apartment; he employs all his efforts to dilate the chest, and then to empty the lungs. There is restlessness; occasional cough, which the patient makes efforts to perform, thinking to force something out of the lungs which impedes his breathing. Expiration is performed with a peculiar whistling sound, and sometimes it is sonorous. The face is either pale or livid. The eyes have an anxious expression. The extremities are frequently cold, even the nose and the ears; and 456 ASTHMA. the face and breast are covered with a cold dew. The pulse is in various states,—full and quick,—small and quick,—sometimes op- pressed;—and it occasionally intermits. The skin is frequently dis- coloured; and there is often a troublesome flatulency and sense of ful- ness in the abdomen. These symptoms continue with more or less violence for some hours, or days, till expectoration takes place, which generally precedes a remission. The expectoration is sometimes scanty, at others copious. This is a short description of the symptoms as they generally occur. In slight cases, however, a sense of constric- tion in the chest only is complained of, which is sometimes relieved by the expectoration of a whitish mucus; but in more severe instances, the symptoms are much more violent and alarming, not only to the patient, but to the by-standers; instant suffocation being threatened, and he solicits relief in the most pitiful manner. An individual may have an attack for three or four successive nights, and not be again affected for months; sometimes it returns every month, for a number of years, and then disappears for a considerable time; women are generally attacked immediately preceding the cata- menia. The duration of each paroxysm is very various, from two or three days to three or four hours. One attack leads to another, and the paroxysms generally become more and more frequent and severe. In describing this disease, authors have mentioned two varieties,— the humid and the dry. The first commences more gradually, and becomes slowly worse; the cough is frequently severe, attended with early and copious expectoration, which produces relief; and the mu- cous rale is heard almost from the beginning. The dry asthma com- mences suddenly, and becomes quickly severe, but does not continue long. The cough is slight; the expectoration very scanty, and ob- served at the close of the paroxysm only; the mucous rSle is not heard till towards the conclusion of the attack,—even then it is very slight, and perhaps partial. Causes.—Asthma is liable to return occasionally during he whole period of a man's life. The subsequent attacks depend on different circumstances in different constitutions. Some are affected by exter- nal heat, others by external cold; many by overloading the stomach; and almost all asthmatics are affected by hurried exercise, and by any other cause which increases the rapidity of the circulation. It will generally be observed, that those who are predisposed to it, dread cold, moist weather, and stormy seasons. Individuals who follow particu- lar occupations, would seem to be more subject to this affection than others, particularly those who are exposed to irritating vapours, and ASTHMA. 457 breathing an atmosphere in which different substances, in tery fine powder, are suspended. Causes particularly affecting the nervous sys- tem, would also seem to be capable of producing paroxysms, such as passions of the mind, &c. Pathology.—It is generally admitted, that that kind of dyspnoea which is now under consideration, and which is commonly known by the name of asthma, is produced by various diseased states of the lungs and heart. Chronic bronchitis, emphysema, and congestion, are the three conditions of the lungs which most frequently produce asthma; and I believe it is likewise occasioned by some kind of ner- vous irritation, the nature of which is yet unknown. It is, perhaps, from this view, that the doctrine of a spasmodic structure in the air- tubes has arisen. Having already treated of chronic bronchitis, it is unnecessary to say more upon the subject in this place; I shall therefore proceed to describe emphysema of the lungs, of which there'are, according to Laennec, two kinds; 1st, That which consists in the simple dilatation of the air-cells, which he calls pulmonary or vesicular emphysema; and, 2d, That which is characterized by infiltration of air between the lobules of the lungs, which he terms interlobular emphysema. In the first, the size of the vesicles is much increased, and also less uniform; the greater number equal or exceed the size of a millet-seed, while some attain the magnitude of cherry-stones, or even French beans. The largest are, in all probability, produced by the union of several of the air-cells, in consequence of the rupture of the interme- diate partitions; sometimes, however, they appear to arise from the sim- ple enlargement of a single vesicle. The bronchial tubes, especially the small ramifications, are sometimes very evidently dilated in those portions of the lung where the emphysema exists. The interlobular emphysema, according to the same author, is char- acterized by infiltration of air between the lobules of the lung, and must be considered as necessarily depending on a rupture of some of the air-cells in the first place, and the consequent extravasation of the air contained in them. When the extravasation exists near the root of the lungs, it sometimes extends to the mediastinum, thence crosses to the neck, and occasionally spreads over the whole subcutaneous and intermuscular-cellular substance of the body. " The pathognomic signs of the pulmonary emphysema," says Laen- nec " are furnished by a comparison of the indications derived from percussion and mediate auscultation. The respiratory sound is inau- dible over the greater part of the chest, and is very feeble in the points Vol. I.—58 458 ASTHMA. where it is audible; at the same time, a very clear sound is produced by percussion. From time to time, also, we perceive, while exploring the respiration or cough, a slight sibilous rattle, or sound of the valve, as in the dry catarrh, occasioned by the displacement of the pearly sputa." When existing in a high degree, it may be recognized by a sign which is altogether pathognomic, which Laennec calls, the crepi- tous rattle with large bubbles. "In this case, the sound during inspi- ration or coughing, is like that which would be produced by blowing into half-dried cellular substance." (Page 158.) In the inter-lobular emphysema, Laennec assures us "there is one sign completely pathognomic, viz. the dry crepitous rattle with large bubbles, when very distinct and continuous, or nearly so. Together with this sign, (continues he,) we usually perceive, during inspiration and expiration, a sound or sensation as of one or more bodies rising and falling, and rubbing against the ribs." (Page 171.) Emphysema of the lungs is a common disease in horses, and is the great cause of what is called broken-wind; and is more common in man than is generally imagined. It is produced by various causes, as lifting a heavy weight; it occurs during the act of bearing down in labour; but more frequently it is a consequence of violent coughing in cases of bronchitic inflammation; indeed, I scarcely every witness a dissection of a person who died of bronchitis or hooping-cough, without seeing pulmonary emphysema. For a more particular account of these morbid states, the reader is referred to the work of Laennec. There cannot be a doubt but that the nervous system has a power- ful influence on the functions of the lungs, when labouring under disease, as well as in health; and I imagine no one can deny that asthma may be produced either in consequence of some diseased action of the brain, or in the nerves themselves which supply the lungs. It has been attempted to be shown, by Reisseissen and Laen- nec, that the bronchial tubes possess a muscular structure, through the agency of which the air-vessels contract, when under the influence of spasm; but this is not a new idea on the part of Reisseissen or Laen- nec, for Cullen makes the following statement:—" From the whole of the history of asthma now delivered, 1 think it will readily appear, that the proximate cause of this disease is preter-natural, and in some measure, a spasmodic constriction of the muscular fibres of the bronchiae which not only prevents the dilatation of the bronchia ne- cessary to a free and full inspiration, but gives also a rigidity which prevents a full and free expiration," (Par. 1384.) But neither is ASTHMA. 459 this an original idea of Cullen's, for it was entertained long before his time by Hoffman and Willis. It is foreign to the object of this work, to enter into anatomical controversy, and unnecessary in this in- stance, for even Laennec states that he had " met with only a very small number of asthmatics, in whom there was evidence of pulmo- nary spasm, without any attendant catarrhal affection; but some few I have met with. On the other hand, I have known a great number of patients, in whom the catarrh, whether dry, pituitous, or mucous, was too slight in degree, or too small in extent, to be considered as the real cause of this asthma." (Page 412.) Because, perhaps, there might be in these cases some organic lesion of the heart and large vessels, or the co-existence of cerebral irritation. These observations lead me to remark, that there is almost always something more in this disease than in the original organic lesion in the lungs themselves; this experience has frequently led me to trace to sudden congestion of the lungs, which flattens the air-vessels, and prevents them from dilating. Various diseases of the heart produce asthma; the most frequent are dilatations of its cavities, diseases of its valves; and aneurism of the aorta, of which more hereafter. Treatment.—From want of attention to the pathological condition of the body, the treatment of asthma has hitherto been uncertain and empirical. Some highly extol one remedy, and some another; some always use the lancet, and others invariably condemn it Although an advocate for occasional bleeding in asthma, yet I am convinced, that no remedy, except the indiscriminate use of opium, has done more mischief. There are only two circumstances in which bleeding should be had recourse to; 1*/, where we have evidence of acute action in any of the tissues of the lungs, superadded to any of the or- ganic lesions already mentioned; 2dly, when there is much venous engorgement of the lungs. In old chronic cases, it must be a doubt- ful, and occasionally a dangerous remedy. Dr. Bree assures us, that he repeatedly tried bleeding, but does not think the paroxysm was ever shortened an hour by the remedy; and in old people he found it injurious. It may be mentioned, that Dr. Bree was himself an asthmatic and after paying much practical attention to the disease, he wrote a treatise upon the subject, which is worthy of perusal. Bleed- ing must be employed early in the paroxysm, or not at all, unless the patient is threatened with suffocation. The pediluvium is to be instantly had recourse to, which I have seen sometimes of itself arrest a paroxysm; as well as inhaling the vapour of hot water. The apartment is to be 460 ASTHMA. freely ventilated, and too many people are not to remain in the room. Laxatives are always necessary. Vomiting is a favourite remedy with many, and is useful principally in two cases,—when there is evidence of a load of food being in the stomach,—and when we know the disease depends upon chronic bronchitis. In the last case, vomiting will assist in clearing the air-passages of superabundant mucus. In almost all cases, counter-irritation is useful, whether produced by mustard plas- ters, stimulating embrocations, or blisters. Strong coffee was formerly recommended by Sir John Floyer, from the relief he experienced in his own person, and it has since been as highly lauded by his fellow- sufferer, Dr. Bree. With respect to opium, very opposite opinions have been maintained. Laennec speaks strongly in favour of the whole class of narcotics, with a view of producing sleep, upon the theory of bringing patients so affected as nearly as possible to the level of bats, and other animals which hybernate, and consume nearly a hundred times less air when in a state of torpidity. He seems to have been influenced by an idea of producing relaxation of the muscular fibres of the air-tubes, thereby overcoming the spasm of the lungs. The following narcotics are recommended by Laennec,—opium, bella- donna, stramonium, phellandrium aquaticum, aconitum napellus, col- chicum, tobacco smoked or taken internally, cicuta, dulcamara, h3'os- ciamus. With respect to tobacco, it may be mentioned, upon the authority of Dr. Ferrier, that Baglivi used the "julapum tabaci" in cases of asthma. (Reflections, p. 204.) If the disease generally depended on spasm, opium would be useful in a great number of cases, but I am convinced, from what I have seen in practice, that it is the most dangerous of all the remedies which have hitherto been recommended. Dr. Bree tells us, that four grains nearly sent him into the next world. In truth, it is a remedy which must very often interfere with the efforts of the constitution for re- lieving the patient; more particularly in the form of the disease pro- duced by chronic bronchitis, when opium, by allaying the cough, promotes a collection of mucus in the air-passages: hence the com- mon observation, that opiates dry up the expectoration. I have seen some individuals very much relieved by smoking tobacco, and some by smoking stramonium. As the disease is frequently observed to terminate by expectoration, the class of medicines called expectorants has been much employed. In fact, if routine practitioners are asked what should be done for a patient in a fit of asthma, they will be found either to order bleeding, or to give an expectorant. I have seen them often tried, but very ASTHMA. 461 seldom with any good effect. Of this class, squills is much in use, together with the foetid gums. [I have known great relief to be derived from frequently bathing the feet in hot salt and water.] After the paroxysnt is over, tonics are frequently recommended. Dr. Bree speaks much in praise of Fa remedy composed of nitric acid, hyosciamus, and squills. Some tell us to avoid warm bathing, and to use the cold bath as a tonic during the intervals; the cold bath agrees with some better than the warm, and I have seen both do much mis- chief. [The best tonic is carriage exercise; some patients being most bene- fitted by a dry, and others by a moist, atmosphere.] Issues, setons, and cauteries, have all been used as counter-irritants, and it is worthy of remark, that many fits of asthma have taken place immediately after the disappearance of a cutaneous eruption. I have myself witnessed examples of this kind, and I have been acquainted with asthmatics who were occasionally affected with cutaneous erup- tions, and who, although they complained of much distress from the itching and tingling of the skin, were yet contented with their lot, and invariably expressed themselves as being certain of an attack of asthma if they were repelled. The observation of such circumstances, has led me to insist much on the propriety of employing counter-irri- tation in all diseases of the chest, but particularly those of a chronic nature. The sub-carbonate of iron has been recommended, but I cannot speak from experience of its effects. Galvanism is another remedy which has been much lauded, not only in this country, but on the continent. Dr. Wilson Philip, to whose ex- ertions in endeavouring to improve the science of medicine, the pro- fession stands deeply indebted, directed his attention to this subject. He made many experiments on animals, in conducting an inquiry into the laws of the vital functions; and among others, he divided the pueumogastric nerves, in order to diminish the nervous influence in the luno-s and stomach; the digestive powers were found to be thereby much impaired or suspended, and dyspnoea was produced. He then directed galvanic influence towards the lungs and stomach, and he observed that the animal could be made to breathe easily, and digest its food. After these experiments had been repeated and confirmed, Dr. Wilson Philip was naturally led to inquire what diseases de- pended on a failure of the nervous influence. Judging from analogy and observation, he thought it probable that indigestion and asthma 462 ASTHMA. were two, at least, of the number. This is a short view of the cir- cumstances which led Dr. Wilson Philip to expect relief from galvan- ism in habitual asthma; which name he has given to that form of the disease, in which the breathing is constantly oppressed,—better and worse at different times, but never free,—and often continues to get worse in spile of every means we can employ. He states, that he has used galvanism in many cases, and almost uniformly with relief, applying as much of the galvanic influence as patients could easily bear. The period varied from five to fifteen minutes, before relief was experienced; and he generally found, that the stronger the sen- sation excited, the more speedy the relief; he found from eight to fifteen four-inch plates of zinc and copper sufficient; the fluid used was one part of muriatic acid to one hundred and twenty of water. Some people required more than sixteen plates, and a few could not bear eight. It is a curious fact, that on the first application of gal- vanism, a person may experience little sensation from the operation of twenty-five or thirty plates, yet afterwards he may not be able to bear more than six or eight. He applied it in the following manner; —he placed two thin plates of metal dipped in water, one on the nape of the neck, the other on the lower part of the epigastric region. The wires from the different ends of the trough were brought in contact with the plates; in this way, the galvanic influence was sent through the lungs, as much as possible in the direction of the nerves. The operation was discontinued as soon as the patient said his breathing was easy, any further application being found quite unnecessary. We are assured, that this means afforded relief to those who had laboured under oppressed breathing for ten or twenty years, as readily as in more recent cases; therefore, we must join Dr. Wilson Philip in taking this as a proof, that no organic lesion existed in the lungs. For further information on this interesting topic, the reader is referred to his work, entitled," Inquiry into the Laws of the Vital Functions." Whatever differences of opinion exist respecting the nature and seat of asthma, and the treatment proper to be pursued during a par- oxysm, all agree in recommending, that the diet of an asthmatic should be light, nourishing, and easy of digestion; that his clothing should be warm; and that he should avoid exposure in cold damp weather, particularly when the wind is in the east. The bowels should be kept easy, but it is proper to mention, that I have known a paroxysm brought on by hypercatharsis as well as constipation. RECENTLY PUBLISHED BY KEY & BIDDLE, No. 23, MINOR STREET. THE PHILOSOPHY OF A FUTURE STATE. By Thomas Dick, author of the Christian Philosopher, &c. In the work whose title heads this article, Mr. Dick pride of the philosopher, and painful to the scnsibili- tios of the philanthropist. We need notrat this enlightened period, enlarge on the general diffusion of knowledge, as a means of ele- vating the scale of social existence, and humanizing has endeavoured to prove, that nianTs "an ^'iiimortai i and 8nftpning the feelings of men. Dr. Dick, in the being. Ilis arguments are drawn from various sources and he has judiciously availed himself of the recent discoveries in science, in illustrating the connexion of intellectual improvement, with the state of future ex- istence. Mr. Dick has displayed in this work,considerable ex- tent of knowledge, and the industry manifested in col- lecting and arranging his numerous and diversified materials, will moot with the decided approbation of every intelligent Christian. THE PHILOSOPHY OF RELIGION, or an Illustration of the Moral Laws of the Universe. By Thomas Dick. The Philosophy of Religion is a production of no less value than the preceding. It is an attempt by the pious ami indefatigable author, to illustrate the moral being of the universe, and to delineate the obligations of man to God—to show how reasonable and excellent the pre- cepts of revealed religion are, and how well they are adapted to the condition of man, how certainly their practical adoption is productive of peace and joy, and how bright under all circumstances are the hopes, and soothing the consolations of the Christian. It is an excellent book, and may be read with advantage, by all sects of Christians.—Christian Intelligencer. THE CHRISTIAN PHILOSOPHER, or the Connection of Science and Philosophy with Religion. By Thomas Dick, The Christian Philosopher, is to the philosophic in- quirer more interesting than cither of the preceding two. It is a scientific investigation into the existence and attributes of a. great first cause, and the author has evidently come to his subject well prepared, securely assured, and ready to give a reasonable answer to the sceptical questioner for the hope that is within him. The author has successfully combated the ridiculous ideas of those zealous but ignorant Christians who re- ject all human knowledge as vain and useless. He has shown that the study and contemplation of the laws of the natural world, elevate the mind in its concep- tions of the power, wisdom and goodness of God, and that every advance in knowledge, every discovery in science, tends to confirm our faith, exalt our views and refine our dispositions, and thus improve us in moral and religious feelings and principles.—Christian Intcll. THE IMPROVEMENT OF SOCIETY, by the Diffusion of Knowledge; or an Illustra- tion of the advantages which would result from a general dissemination of rational and scientific information among all ranks. Illustrated with engravings. By Thomas Dick, LL. D., author of Philosophy of a Future State, &c. In the contemplation of the history of the human race, the observer is forcibly struck, at every step of his inquiry, with the conviction, that with every advance of knowledge, and enlargement of his intelligence. there has been a corresrK>nding improvement in the so- cial feelings and moral principles of man. Christianity itself, without the aid of the sciences, would not effect that regeneration of man which is necessary for the advanclm" nt of civilization and the perpetuity of so- cia?"n1mut,ons. The page of history confirms our assertions and we need but refer to the dark ages when fhfehristia "world, under the dominion of the Vat.- an presented a prospect at once humiliating to the work before us, has learnedly and eloquently exhibited the evils of ignorance, and in bold relief portrayed the advantages of the general diffusion of knowledge. His work is equally creditable to his head ana heart, and we desire to see it extensively circulated through- out all classes of the community. A variety of topics are discussed, and every subject is rendered plain and of easy comprehension by the most simple illustrations. Philoso.phy, mechanics, astronomy, superstition, and a multitude of other matters are touched on, and the whole adapted to the popular mind. The work is not only highly valuable, but, apart from this, it is very in teresting and entertaining. It is not a dry, abstract, metaphysical discussion, but a plain, intelligible and agreeable survey of the benefits of knowledge, and the evils of ignorance. Historical facts, interesting anec- dotes, familiar explanations of the principles of science, characterize this production, and the most ordinary understanding will find amusement and instruction in its perusal.—Southern Religious Telegraph. A MANUAL OF THE CHRISTIAN SAB- BATH, embracing a consideration of its Perpetual Obligation, Change of Day, Utility, and Duties; by John Holmes Ag- new, Professor of Languages, Washington College, Pa.; with an Introductory Essay, by the Rev. Dr. Miller, of Princeton. This is a valuable work, well adapted for general cir- culation through the community,—and truth requires us to add, it is a book which is greatly needed. The in- formation it gives, could it be imparted to the many, might save our country from the greatest evils, which threaten it. The subject it discusses is one of incon- ceivable moment to the interests of religion, and to the prosperity of a Christian people. The introductory essay is ably written. The facts and considerations it con- tains on several branches of the general subject, are worthy of the special attention of readers of every class. The writer's statements respecting the views of the Christian Sabbath, entertained by the primitive church- es, and the manner in which they sanctified it, are high- ly interesting, and instructive. Mr. Agnew's Manual is divided into five chapters, on the following subjects: the institution of the Sabbath ; its perpetual obliga- tion ; change of day ; its utility; and its duties. Under these several heads, the claims of this wise and bene- volent institution, reared for the whole world, for the benefit of man through all time, are presented with great clearness and ability. The argument of the author on the moral nnture and perpetual obligation of a week- ly Sabbath, to be devoted exclusively to the service of God, is lucid, forcible and well sustained; and to an unprejudiced mind, satisfactory.—Southern Rel. Tel. PAROCHIAL LECTURES ON THE LAW AND THE GOSPEL. By Stephen H. Tyng, D.D. Rector of St. Paul's Church, Philadelphia. As an evideuce of the great value of the work, we beg leave to submit the following letter from Dr. Alex- ander :— Messrs. Key # Biddle.—Gentlemen :—Your request that I should furnish you with a recommendation of the Rev. Dr. Tyng's Lectures, " On the Law and Gos- pel," has been received. In answer, I feel a perfect freedom in declaring, that in my humble opinion, these discourses, recently published in "The Christian Li- brary," are sound and evangelical; and well calculated to lead men to just views of their sinful and miserable condition, as transgressors of the holy and immutable WORKS RECENTLY PUBLISHED i law of God ; and of the only method of recovery from this deplorable state of guilt, pollution, and helpless- ness, through the perfect righteousness of our Lord and Saviour Jesus Christ, and the sanctification of the holy Spirit. The author of these Lectures has laid a solid foun- dation for the views which he gives of the gospel plan of redemption, by exhibiting the holy law of God, in its indispensable obligation, its uuiversal extent, its spiritual nature, and awful penalty. It is only by such an exhibition of the law as is here given, that sinners will be led to appreciate the salvation of the gospel. Our estimation of the value of a remedy always bears a relation to the impression which we have of the ma- lignity and inveteracy of the disease. Mistakes respect- ing the law, always run through, and vitiate the whole system of theology, with which they are connected. Not only is the error of Antinomians great and dan- gerous, but often they, who declaim most loudly against these avowed enemies of the law, fall into a similar error, on the other extreme ; for the proverb is verified, " that extremes often meet." I refer to all those (and they are numerous,) who teach that the law of God no longer requires perfect obedience, but only that which is sincere, and within the power of fallen man ; that Christ, by his meritorious death, has procured a relaxa- tion of the moral law, so that sinners can still be justi- fied by their own evangelical obedience. This system, however specious and popular, is Antinomian, and more dangerous than open Antinomianism, because more plausible, and more common. The foundation on which such opinions rest, is completely swept away, in these Lectures on the law. The author is equally clear and explicit on the me- thod of justification by faith. While, by so many, this cardinal doctrine of the reformation is perverted, ob- scured, or placed in the back ground, it is pleasing to find any one disposed to come forward boldly in its de- fence, and at the same time to guard it against abuse, and to show that its tendency is not to subvert, but to establish and magnify the law. The discourses on the gospel, ara a fair counterpart of those on the law. They are rich in evangelical truth, and adapted to introduce and guide men into the way of salvation. I do, there- fore, cordially recommend these Lectures to the serious and candid perusal of all into whose hands they may come. There arc, indeed, no pruttiness of style, nor flames of rhetoric to be found hero. The author was too seriously intent upon his great object of saving sinners from eternal ruin, to turn aside in pursuit of such cmbelli>liments. But I mean not to make myself answerable for every minor opinion, or form of expression adopted by the author. From a few things, as expressed, I would dis- sent ; but even in regard to these, upon close exainina- ] tion of the meaning, I have been led to conclude, that j the difference of opinion is more in appearance than j reality ; more in words than in things. It will be readily believed that I have penned the above recommendation from a sincere desire to give extensive circulation to the truths inculcated in these discourses, and not from any partial or sectarian feel- ings ; since, with the author I have not the pleasure of any personal acquaintance; and since he is a minister of a denomination to which I do not belong. I am, very respectfully, yours, &c. A. ALEXANDER. Princeton, JV. J. Sept. 30, 1834. COUNSELS FROM" THE AGED TO THE YOUNG. By Dr. Alexander. This is a volume which may be carried conveniently in the pocket, and consulted as a suitable vade mecum for youth. When the piety, experience and general reputation of the author are considered, they must su- persede the necessity of commendation from us—they afford the surest guarantee to the purchaser.—The Pres- byterian. AN ESSAY ON THE SPIRIT AND IN- FLUENCE OF THE REFORMATION. A work which obtained the prize on the following question proposed by the National Institute of France :—" What has been the influence of the Reformation by Luther, on the political situation of the different states of Europe, and on the progress of know- ledge T' By C. Villers, sometime Professor of Philosophy in the University of Gottin- gen. Translated from the French. With an Introductory Essay, by Samuel Miller, D. D., Professor in the Theological Semi- nary at Princeton, N. J. The National Institute of France proposed the fol- lowing as a prize question:—"What has been the in- fluence of the Reformation, by Luther, on the political situation of the different states of Europe, and on tlie progress of knowledge?" Among the competitors was C. Villers, Professor of Philosophy in the University of Gottingen, and to him the prize was adjudged. Villers was not an ecclesiastic or sectarian, but a philosopher, and treats the subject in a philosophical manner. Those who are interested in tracing the causes that have given direction to the course of human events, will be richly rewarded by a perusal of this Essay. Christian Intelligencer. AN ADDRESS TO THE YOUNG, by John Foster, author of Essays on Decision of Character. John Foster is allowed by men of all parties, political and religious, to be one of the most original and vigor- ous thinkers of the age. His well-tried talents, his known freedom from cant and fanaticism, and the im- portance of the subject discussed, strongly commend this book to the attention of that interesting class to whom it is addressed. All his writings are worthy of careful and repeated perusal; but his essay on "De- cision of Character," and this " Address to the Young,11 should be the companions of all young persons who are desirous of intellectual and moral improvement.— Epis. Recorder. BEAUTIES OFlToBERT HALL. ' If Robert Hall wrote comparatively little, what he did write bears the impress of genius, united with piety. He was a luminary of the first order, and it is delightful to feel the influence of his beams. To those who cannot obtain his whole works, we recommend this choice selection, which certainly contains many bean in-.—Episcopal Recorder. The " Beauties of Robert Hall," which have just boon published by Key & Biddle, contain selections from bis various writings. They are beautiful Bprcimen* of chastened and pure composition, and are rich in senti- ment and principle. These extracts contain much useful matter for reflection and meditation, and may be pe- rused by the old and the young, the grave and the gav, the learned and the illiterate, with advantage. We have rarely seen in so small a space so much powerful Mniuirht as is exhibited in this little volume.—Boston Er. Gaz. ---- LETTERS TO AN ANXIOUS INQUI- RER, designed to relieve the difficulties of a Friend, under Serious Impressions. By T. Carlton Henry, D. D., late Pastor of the Second Presbyterian Church, Charleston, S. C.; with an Introductory Essay, (in which is presented Dr. Henry's Preface to his Letters, and his Life, by a friend.) By G. T. Bedell, D. D., Rector of St Andrew's Church, Philadelphia. We have perhaps never read a book, except the Bible, with whose sentiments we could more exactly accord, and few which appear to us better c aleiilated to be use- ful, than those letters. Dr. H. appears to have a com mon sense view of every subject in his letters, and these views seem to have been formed from a practical acquaintance with the matters of which he treats. When these letters shall be known, thev will be es- teemed an important treasure, not onlv by anxious in- quirers, but by those -who have any concern in religions instruction ; and will be regarded as a valuable closet companion to the practical Christian.— Hartford Chris- tian Intelligencer. In a revival of religion among his own people, Dr. Bedell found this work useful, and was led to seek its republication in a cheap and neat form, for the advan- tage of those who cannot aflbrd to purchase costly volumes. We hope the work mav prove a blessing to all who shall read it — The Pltiladilphian. These letters'have been for many years highly valued for the practical and appropriate instruction for which they are principally designed.—Presbyterian BY KEY & BIDDLE. THE TESTIMONY OF NATURE AND REVELATION TO THE BEING, PER- FECTK )NS, AND GOVERNMENT OF GOD. By the Rev. Henry Fergus, Dun- fermline, author of the History of the Uni- ted States of America, till the termination of the War of Independence, in Lardner's Cyclopedia, The Rev. Mr. Fergus's Testimony of Nature and Revelation to the Being, Perfection, and Government of God, is an attempt to do in one volume what the Bridgewater Treatises are to do in eight. We wish one-eighth of the reward only may make its way to Dunfermline. Mr. Fergus's Treatise goes over the whole ground with fervour and ability ; it is an excel- lent volume, and may be had for somewhere about half the price of one Bridgewater octavo.—London Spectator. A work of great research and great talent.—Evan- gelical .Magazine. A very seasonable and valuable work. Its philosophy is unimpeachable, and its theology pure and elevated. Jtoio Monthly Mag. This is an elegant and enlightened work, of a pious and highly gifted man.—Metropolitan Magazine. This oxccellent work contains, in a brief space, all that is likely to be useful in the Bridgewater Treatises, and displays infinitely more of original thought and patient research, than the two volumes which have been recently published by the managers of his lord- ship's legacy. We have never seen any work in which the necessity of a revelation was more clearly demon- strated, while at the same time its due importance was assigned to natural religion. We hope that the work will be extensively used in the education of youth ; it is admirably calculated to stimulate students to scientific research, and the obser- vation of Nature; it suggests subjects of contempla- tion, by which the mind must be both delighted and instructed; and, finally, it teaches the most sublime of all lessons, admiration of the power, delight in the wisdom, and gratitude for the love of our Creator.— Athenaum. AN ADDRESS TO THE YOUNG, ON THE IMPORTANCE OF RELIGION. By John Foster, author of Essays on Deci- sion of Character, &c. We are not going to hold a rush-light up to a book of John Foster's, but only mean to tell what is its in- tent. It is an awakening appeal to youth of the re- fined and educated sort, upon the subject of their per- sonal religion. There can be no doubt as to its curren- cy.— The Presbyterian. A MOTHER'S FIRST THOUGHTS. By the author of " Faith's Telescope." This is a brief miniature, from an Edinburgh edition. Its aim is to furnish Religious Meditations, Prayers, and Devotional Poetry for pious mothers. It is most highly commended in the Edinburgh Presbyterian Re- view, and in the Christian Advocate. The author, who is a lady of Scotland, unites a deep knowledge of sound theology, with no ordinary talent for sacred poetry.— Presbyterian. A HARMONY OF THE FOUR GOSPELS, founded on the Arrangement of the Har- monia Evangelica, by the Rev. Edward Greswell. With the Practical Reflections of Dr. Doddridge. Designed for the use of Families and Schools, and for Private Edifi- cation. By the Rev. E. Bickersteth, Rec- tor of Wolton, Herts. A beautiful duodecimo of about four hundred pages ; and one of the best books which has appeared for many years with respect to personal and domestic edification. It is next to impossible to read the ordinary Harmonies. The current of the narrative is broken by constant in- terruptions. In this, we have in convenient sections, the fourGospil histories, made up into one, in proper order, in the words of the common English translation. The devotional notes of Doddridge are better than any we have seen for reading in the closet, or at family worship. The name of Bickersteth, prefixed to a book, is enough to show that it is written simply to servo the cause of Christ.—The Presbyterian. THE HAPPINESS OF THE BLESSED, considered as to the particulars of their state; and its difference of degrees. To which are added, Musings on the Church and her Services. By Richard Mant, D. D. M. R. I. A. Lord Bishop of Down and Connor. The design of the Rev. author in this production, is to adduce from scriptural authority, the most satisfac- tory evidence of the happiness and joy of those who by faith follow Christ, and who, in the exercise of those virtues required by the gospel, are emphatically deno- minated the children of God. The author has touched upon several topics connected with the subject, which must afford much consolation to the Christian, who, from the very nature of his organization, is liable to doubts and fearful forebodings as to the state of his heart and the grounds of his faith. Christian hope, confidence, and charity, are stamped upon every page, and the writer deserves well of the Christian inquirer, for the industry which be has dis- i played in collecting and arranging so many important and valuable arguments in favour of the glorious and resplendent state of the faithful and humble disciple of Jesus. In this world, mankind have need of consolation— of the cup of sorrow all must drink—happiness ii a phantom, a meteor, beautiful and bright, always al- luring us by its glow—forever within our reach, but eternally eluding our grasp. But this state of things was designed by our Creator for our benefit—it was in- tended to withdraw our affections from the shadowy and unsubstantial pleasures of the world, to the Father of all in Heaven, and to prepare, by discipline and zeal, for a state, beyond the grave, of felicity, which eye hath not seen, car hath not heard, neither bath it en- tered into the heart of man to conceive of. To our readers we cheerfully commend this delightful volume, confident that by its perusal the faith of the doubtful will be confirmed, and the anticipativc hope of the con- fident increased.—Christian's Magazine. We take the earliest opportunity of introducing to our readers this excellent little book, to which the deeply interesting nature of the subject, and the well- earned reputation of the Right Rev. author will secure no inconsiderable portion of attention. The vast im- portance of the topics herein treated, and the valuable practical effects they may assist in producing, induce us to call thus early the public attention to a work, small indeed in size, but which is calculated not a little to inform all candid and serious inquirers upon a sub- ject hitherto involved in much obscurity, but not a lit- tle elucidated by the present author.—dent. Mag. GENERAL MEW OF THE GEOLOGY OF SCRIPTURE, in which the unerring truth of the Inspired Narrative of the early events in the world is exhibited, and dis- tinctly proved, by the corroborative testi- mony of physical facts, on every part of the earth's surface. By George Fairholme, Esq. The work before us is admirably calculated to en- lighten the mind upon the subject of Creation, and we have rarely perused a work which has added so much to our stock of ideas, or which has given so much gratifi- cation. If the limits of our paper permitted, we should take pleasure in laying before our readers an analysis of the contents of this excellent production, but as that is out of the question, we must refer them to the work itself, where we can assure them they will find an abundance of information on the important subject of Creation.—Phil. Gaz. The Geology of Sc ripture, by George Fairholme, Esq. is an admirable work. The circulation of it should be extensive; and. judging from its intrinsic merit, such is ita destiny.—Christian Gazette. WORKS RECENTLY PUBLISHED -1 MEMOIR OF MISS MARY JANE GRA- HAM. By the Rev. Charles Bridges, M. A. author of Christian Ministry, &c. &.c. We have seldom read a biographical sketch which we could more cordially or confidently recommend to the Christian reader. The highly gifted, accomplished, and spiritually-minded subject of the work has found a kindred spirit in the excellent author. He has used his valuable materials in such a manner as to render the memoir of Miss Graham not less rich in interest than full of instruction, to all who are capable of being interested in the highest mental endowments, sanctified and set apart to the service of God. There are few, either believers or unbelievers, wlio may not be in- structed by the counsel, or benefited by the example of Miss Graham.—Episcopal Recorder. In many respects it is one of the richest pieces of biography with which we are acquainted.—Presbyte- rian. LIFE OF WILLIAM COWPER, ESQ.; compiled from his correspondence and other authentic sources of information, containing remarks on his writings, and on the pecu- liarities of his interesting character, never before published. By Thomas Taylor. Taylor's Life of Cowper has several private letters of the poet not found in other works, which serve to correct many false impressions relative to his mental aberration. It is due the cause of humanity, and of justice generally, that the truth should be received; especially when, by affecting the character of so great a man as Cowper, it in a great measure touches the whole of the human kind.— U. s. Git:. A comprehensive and perspicuous memoir of Cowper has been much wanted, and will be read with gratifi- cation by the admirers of this amiable and pious man, whose accomplishments, excellencies, and peculiarity of character, have rendered him an object of interest to the world. We are indebted to Mr. Taylor for his excellent work, and for the happy manner in which it has been accomplished.—Boston Trav. Thirty years nearly have passed since we first read with great delight Ifayley's Life of Cowper, and we have never cast our eyes on the volumes since, without wishing to unravel a few things in the poet's history which were then left in mystery. Taylor professes to deal openly, and remove all concealment. In one beau- tiful volume, he has given us the substance of all which is known concerning the most sensible and pious of all the English poets; whose writings will be regarded as the best of their kind wherever the English language shall be read. In all his numerous works, he has no line of measured jingle without sense. Can this be said of scarcely any other child of the muses? Those who have Ilayloy's two volumes, will be thankful for the labours of Taylor; and those who have neither, should purchase this new compilation without delay. It is a work which will be found interesting to all classes, especially to the lovers of literature ami genuine piety, and to place within the reach of general readers, many of whom have neither the means nor the leisure to con- sult larger works, all that is really interesting respecting that singularly afflicted individual, whose productions, both poetic and prose, can never be read but with delight. —Philadelphia^. Messrs. Key & Biddle deserve credit for placing within the reach of all. in so cheap and convenient a form. what must be salutary in every instance in its general effect. The character, pursuits, performances, and suf- ferings of Cowper, combine more interest than belongs to the life of any of the great English authors who spent any considerable part of their days in retirement. —JVat. Gaz. A beautiful American edition, from the press of Key ic Biddle, has just been published, and cannot fail to meet with a welcome reception from all who admire that hpst of men and most agreeable of poets. It is the most complete and valuable edition of the Life of Cow- per extant, and contains a well-executed portrait.— Poulson's Daily Adv. MIRIAM, or THE POWER OF TRUTH. By the author of " Influence." This tale is professedly founded on an " anecdote, said to be a well-attested fact, of an American Jew converted to Christianity by the death of his only child, - a beautiful eirl, whom ho had reared with no common care mid affection. f»he embraced the Christian faith unknown to her father, until with her dying lips she confessed to him her aposlacy from Judaism, giving hint at the same time a Testament, with a solemn injunc- tion to believe in Jesus of Nazareth." This outline is ingeniously and skilfully filled up, and a talc of deep interest is produced. There are many passages of deep pat fore, and the argument for Christianity adapted to the Jews, is happily sustained. We think the pleasure and instruction which the book is calculated to afford, will well repay a perusal.—The Presbyterian. The style of writing in this volume is simple and beautiful, as the story is affecting.—Boston Traveller, i The book has enough of fiction to enliven the fancy and gratify the curiosity of youth, who mi^ht not otherwise read it; while it conveys lessons of piety, and arguments for the man of understanding. We wish that many a lovely Jewess could be persuaded loread " Miriam."—The Philadelphia^. The work altogether deserves to stand high hi the class of productions to which it belongs.—Episcopal Recorder. When we see a book which bears the imprint of Key Sc Biddle, we are always sure to see a handsome one. In this case, we can give us high praise to the matter as we can to the mechanical execution. " Influence" was one of the very best of that class of religious novels lately so prevalent in England; anil its gifted young author has even improved upon her- self, in this affecting and powerful story. She has taken that touching incident, well known through the medi- um of our tracts, of a Jewish maiden who, on her dying bed, won over her reluctant father to the religion of the Jesus he despised. It was a subject too good to be left unimproved, and in '• Miriam'" has been embalmed, one of the most beau- tiful and delicate religious narratives we have ever read. No one whose feelings and sympathies are un- corrupted, can peruse this touching tale, without feel- ing a strong interest, and that sympathy which will sometimes melt them into tears. Upon the publication of Miriam in London, it quickly ran through three edi- tions, and we doubt not it will attain a co-extensive populafityTrere, where there is more freshness of the feelings, and a more deeply imbued spirit of rational piety, to appreciate the fine tone of religious spirit which pervades it.—JV. Y. Com. Adv. TITE PROGRESSIVE EXPERIENCE OF THE HEART, UNDER THE DISCI- PLINE OF THE HOLY GHOST, FROM REGENERATION TO MATURITY.— By Mrs. Stevens. This is a work which may be recommended to reli- gious readers and to serious inquirers, with great safety. It is written in an impressive style, and is evidently the production of a mind and heart thoroughly imbued with Christian knowledge and experience. The ope- rations of the Holy Ghost upon the soul of man, are traced with a discrimination which nothing but a per- sonal experience of his influences could have furnished. Doddridge's Rise and Progress of Religion in the Soul, is an admirable book on this subject, but Mrs. Stevens's treatise deserves an honorable place at its side. .Minis- ters of the Gospel should consult the spiritual welfare of their people, by recommending and promoting the circulation of such works.— Presbyterian. PICTURES OF PRIVATE LIFE. Second series. Containing Misanthropy, and The Pains of Pleasing. The aim of the writer is evidently to instruct as well as amuse, by offering these admirable sketches as beacons to warn the young, especially of her own sex, asrainst errors which have shipwrecked the happiness of so many.—Gentleman's Magazine. Those pictures are charming, natural stories of the renl living world; and of the kind which we rejoice to see the public beginning to appreciate and relish; they are delineated in simple and often beautiful language, and with a powerful moral effect.—Tail's Magazine. The object of the writer is to profit, .is well as to amuse; to promote the love of virtue; to exhibit the consequences of vice; and by a delineation of scenes BY KEY & BIDDLE. and characters visible in every-day life, not only to in-1 Some of the ' Scenes' are sweetly touching, and, in culcate what is excellent, but to show what i* prac- our view, the author has succeeded remarkably well in tical.—Scots Times. presenting the sublime and yet simple truths of Evan» We have great pleasure in directing the attention I gelical Religion to the mind in a way of deep and of our readers to this very interesting volume. It is abiding impressions—Jv. 1. Com. Ado. written in a style which cannot fail to entertain, and insure the anxious attention of all who peruse its pages, while the moral sentiments conveyed must recommend it to those who wish to combine instruction with amuse- ment. The work is also embellished with a most beau- tiful frontispiece portrait of the heroine of one of the tales, which is itself worth the price of the volume —Cambridge Chronicle. SKETCHES BY MRS. SIGOURNEY. Com- prising six tales. The Father—Legend of Oxford—The Family Portrait—Oriana— The Intemperate, and the Patriarch. It is the high prerogative of women to win to virtue —it is the praise of Mrs. Sigourney, that her preroga- tive has been exercised far beyond the domestic circle. The influences of her mind have been felt and acknow- ledged wherever English Literature finds a welcome. These Sketches have been sought after with avidity, by those who would profit by the most delightful means of improvement.— U. S. Gazette. Mrs. Sigoumey has a moral object in each of her in- teresting fictions, which she pursues with constant at- tention and effect.—J\'ational Gazette. The Tales and Sketches need no recommendation, as Mthe talents of the authoress, in this branch of litera- ture, are well and favourubly known—they will be read with great interest.—Saturday Ev. Post. The Sketches before us are worthy of the enticing form in which they appear—Mrs. Higourney is a writer of great purity, taste, and power; she seldom exag- gerates incidents ; is simple and unambitious in her diction ; and possesses that magical influence, which fixes the attention, even in a lecital of ordinary events. Her sentiments are touching aod true, because they spring from the holy source of an unhackneyed heart ■ They will add a virtuous strength to the heart of every reader, as well us be an ornament to the library of the owner.—Commercial Intelligencer. To parents the work particularly commends itself, and has only to be known to be eagerly patronised. Young ladies mav foam a valuable lesson from the story of the "Family I'ortrait;" one which they will not be likely soon to forget.—Poulson's Daily Advertiser. This is a beautiful volume in every respect—the style of its execution, its engraving which teaches with the force of truth, and its contents, are alike excellent The graceful simplicity, good taste, classic imagery, and devotional spirit which distinguishes Mrs. Sigoumey's poetry, are happily blended, and presented in living forms in the prosaic " Sketches" before us. In this de- partment of letters, as in poetry, she will be read with interest and delight, be introduced by Christian parents to their children as an accomplished guide and teacher, and receive the well-merited commendation of thou- sands.— Southern Religious Telegraph. THE MORAL TESTAMENT OF MAN. Key & Biddle have just issued under this title, a beautiful little volume made up of the sayings of the wise and good, in olden and modern times. These apothegms are all upon most interesting subjects, each one carrying with it a wholesome as well ns a most agreeable influence. This little volume is to the mind and heart what a flower-garden is to the eye and nose. It delights and regales.—Commercial Herald. Good taste, judgment, and a love of doing eood, must have influenced and directed the industrious compiler. This little selection of precious thoughts has been printed and bound in a style suited to the worth ot She contents-apples of gold in pictures of silver.-£. S. Gazette. EXAMPLE; or, FAMILY SCENES. This is one of those useful and truly moral publica- tions which cannot fail to be read with 'cight by the youth of both sexes, who, as their hearts :^_P»nd._aiirt they advance point out the happiness. Th . in years, have need ot some instructor to o path they should follow for their future , The author has been triumphantly success- ?u?iPnanainh,g those laudable objects in this interest- fng pubI,cation.-/r«*/y Times. __________________ True religion is diffusive in its character, and when it is fairly exemplified in the life of an individual, it will excite attention, command reBpect, and perhaps lead to still happier results. ' Let your light so shine before men that they may see your good works, and glorify your Father which is in heaven,' is a command of high authority, and one which presupposes the force of example. These ' Family Scenes,' which belong to the same class with Mrs. Sherwood's writings, are in- tended to illustrate the influence of example. The book is pleasingly written, and is characterized by a vein of pious and evangelical sentiment.—Presbyterian. LEGENDS OF THE WEST. By James Hall, second edition, containing the follow- ing interesting tales:—The Backwoods- man—The Divining Rod—The Seventh Son—The Missionaries;—The Legend of Carondolet—The Intestate—Michael De Lancey—The Emigrants—The Indian Hater—The Isle of the Yellow Sands— The Barrackmaster's Daughter—The In- dian Wife's Lament. We are glad to see a new edition of these well-told tales of Judge Hall has recently been published.—Bast. Eve. On:. The deserved popularity of these tales of Judge Hall, has secured to them the publication of a second edi- tion. His sketches are admirably drawn, and his per sonal familiarity with scenery and life in the West, have furnished him with incidents of peculiar interest, greatly increased by felicitous description.—.V. Y. Com. Adv. The rapid sale of the first, has created a demand for a second edition of the work, whose title heads Jli is article. The " Legends" comprise twelve articles, one of which is poetic. The scenes of these tales are all located in the " far, far "West," and the characters are taken from the aborigines and early emigrants. The difficulties and dangers which the first .-ettlers had to undergo ere they were established in security, are de- picted in glowing colours, and with a master hand. The rude and savage warfare of the Indians, the secret ambuscade, the midnight slaughter, the confla- gration of the log hut in the prairie and forest, the shrieks of consuming women and children, are pre sented to our minds by the author in vivid and im- pressive language. These tales possess much interest, as they are founded on fact, and are illustrative of the habits of the Indian, and the life of the hunter. As a writer, Judge Hall is more American than any other we possess; his scenes are American ; his characters are American, and his language is American. His person- ages are invested with an individuality which cannot be iui>taken, and his conceptions and illustrations are drawn from the great storehouse of Nature.—Daily Int. THE SOLDIER'S BRIDE, AND OTHER TALES. By James Hall, Esq. author ofi " Legends of the West," &c. Contents.— 1. The Soldier's Bride—2. Cousin Lucy i and the Village Peacher—3. Empty Pock- ets—4. The Captain's Lady—5. The Phila- delphia Dun—6. The Bearer of Dispatches __7. The Village Musician—8. Fashiona- ble Watering-Places—9. The Useful Man —10. The Denti.-t—11. The Bachelor's Elysium—12. Pete Featherton—13. The Billiard Table. We have just risen from the perusal of the Soldier's Bride. The impression it leaves upon the mind is like that which we receive from the sight of a landscape of rural beatity and repose—cr from the sound of rich and sweet melody. Every part of this delightful tale is redolent of moral and natural loveliness. The writer belongs to the same class with Irving and Paulding; and as in his descriptions, characters, and incidents, he WORKS RECENTLY PUBLISHED never loses sight of the true and legitimate purpose of Action, the elevation of the taste aiid moral character of his readers, he will contribute his full share to the creation of sound and healthful literature.— V. S. Gaz. Key & Biddle have recently published another series of Tales—the Soldier's Bride, ice. by James Hall. The approbation everywhere elicited by Judge Hall's Le- gends of the West, has secured a favourable reception for the present volume; and its varied and highly spirited contents, consisting of thirteen tales, will be found no less meritorious than his previous labours.—National Gazette. We have found much to admire in the perusal of this interesting work. It abounds in correct delineation of character, and although, in some of his tales, the au- thor's style is familiar, yet he has not sacrificed to levity the dignity of his pen, nor tarnished his charac- ter as a chaste and classical writer. At the present day, when the literary world is flooded with fustian and insipidity, and the public taste attempted to be vitiated by the weak and effeminate productions of those whose minds are as incapable of imagining the lofty and generous feelings they would pourtray, as their hearts are of exercising them, it is peculiarly gratifying to receive a work. From the pages of which the eye may cater with satisfaction, and the mind feast with avidity and benefit.—Pittsburg Mercury. HARPE'S HEAD, A LEGEND OF KEN- TUCKY. By James Hall, Esq., author of Legends of the West, &c. &c. It is an able production, characteristic of the writer's eminent talents, and abounding with narratives and sketches of absorbing interest. The history of Harpe forms the ground-work of the tale, the incidents of which are developed with much skill and effect.—Phil. Gazette. Harpe's Head is one of the most interesting stories with which we are acquainted.—Daily Chronicle. Judge Hall is among the most popular of American writers, and in the present production, has given an- other proof of the felicity of his genius. It abounds with narratives and sketches of deep interest, relating to the early periods of the settlement of Kentucky.— JV. Y. Com. Adv. Mr. James Hall, a native of Philadelphia, and favour- ably known as the author of Legends of the West, has just published a new work, entitled " Harpe's Head, a Legend of Kentucky." It is well calculated to add to his fame, and though it bears evidences of being a hasty composition, reflects great credit upon the author. It is the story of Micajah Harpe, a Kentuckian Freebooter, and the scene chauges from Virginia, in the olden time, to Ohio and Kentucky. The account of a Virginia Bar- becue is so well and naturally executed, that it must become a favourite. It is here inserted as a specimen of the work. Miss Pendleton is altogether lovely.—Poul- son's Daily Ado. With the ordinary characters which must be found in such a composition, we have qne quite original be- ing, in the person of " Hark Short, the snake-killer;" and the production, as a whole, forms one of the most engaging volumes that we have met with. To its other merits we should not omit to add that, like other wri- tings from the same poll, it is distinguished by an un- obtrusive tone of the purest moral sentiment.—Penn. Inquirer. We cheerfully commend this work to the attention of our readers, assuring them that they will be amused, entertained, and instructed by its perusal—thpy will find Indian warfare,—savage modes of life—the difficul- ties and dangers experienced by the early pioneers in the " far, far west"—delineated with a master hand, 111 language glowing, vivid, and natural.- -.Vat. Banner. THE YOUNG LADY'S SUNDAY BOOK; A Practical Manual of the Christian Duties of Piety, Benevolence, and Self-govern- ment. Prepared with particular reference to the Formation of the Female Character. By the author of " The Young Man's Own Book." We have read many of the selections in this little volume, and have mot with nothing objectionable.— Generally, the style is pure, easy, and pleasing, and the matter good, well calrulitted for the purpose lot which the work is intended, and we cheerfully rccenimend it to the persons fur whom it is principally designed, as profitable for instruction.—Episcopal Recorder. A most attractive little volume in its appearance— and in this age of sweeping frivolity in literature, of far superior excellence in its contents. Certainly Mraa such manual was required for the closet—when novels and light reading of every description have so ruled paramount in the drawing-room. We can give it no higher praise than to say that the extracts are of ft character to accomplish all that the title-page holds out. —JV. Y. Com. Adv. A collection of excellent sentiments from approved authors, and adapted particularly to the formation of ! the female character. The chapters are short, and em- brace a great variety of subjects of religious tendency, and altogether the book is replete with instruction, it is illustrated by two pretty engravings.—Presbyterian. As the public feeling now runs, the publishers of this little work have done well by their effort to keep it in a proper channel. The Young Lady's Sunday Book is altogether practical in its character, and consisting, as it does, of short pieces, takes a wide range in its sub- jects. It is calculated to do good, and we should be happy to see the principles inculcated in the portions we have read, become the ruling principles of all.—Journal and Telegraph. Messrs. Key & Biddle have just issued a volume of the most beautiful kind, entitled The Young Lady's Sunday Book. It is full of pure, didactic matter, the - fruits of a pious and gifted mind; and while the clear- ; ness and light of its pages commend them to the eye, the truth of the precepts finds its way to the heart. The ; work can be unhesitatingly praised, as worthy in all J respects. The embellishments are finished and tasteful. 1 "Meditation" the frontispiece, from the burin of Ellis, would add a grace to any annual. We trust Messrs. Key & Biddle receive a liberal patronage from the re- ligious community, for we know of no booksellers in this country who issue more good volumes calculated to subserve the immortal interests of man.—Phil. Gaz. THE YOUNG MANS SUNDAY BOOK : A practical manual of the Christian duties of piety, benevolence, and self-government; prepared with particular reference to the formation of the manly character on the basis of religious principle. By the author of the Young Man's own Book. This is one of those useful little volumes that will find its way through the world, pleasing and doing good ' wherever it may go. It professes to be a ' Manual of the Christian duties of piety, benevolence, and self-govern- 1 ment, prepared with reference to the/ formation of a : manly character on the basis of religious principle.' It disclaims all sectarian views, or the desire to make proselytes for any party; desiring but to diffuse some- thing of the spirit and practice of Christianity among i the rising generation, and to establish as widely as pos- sible those principles of virtue and goodness which all men profess to respect.—Penn. Inquirer. It is a summary of moral ami religious duties, and is full of useful precepts and excellent admonitions.— Christian Gazette. We have not read it entire—but the evangelical sentiments and ability evinced in parts of it which we have examined, commend it to public favour, and espe- cially to the attention of young men, to whom it may be a useful and valuable counsellor. It contains in a series of essays of moderate length, a summary of Chris- tian duty rather than doctrine, drawn from the writings of those whose names command respect throughout the Christian world. Its design is noble—it is to establish young men in the observance of those grand principles of virtue and goodness, which the holy Scriptures en- force with the sanctions of God's authority, and which all men, the profane as well as the pious, respect.— Southern Religious Telegraph. The Yottug Man's Sunday Book is a Practical Manual of the Christian duties of Piety. Benevolence, and Self- government, prepared with particular reference to the formation of the manly character on the basis of Reli- gious Principle. It professes to be a Summary of duty, rather than of doctrine. Its articles are generally short, and have been drawn from the writings of men whose names command respect throughout the Christian world. It is admirably suited both in its character and form (being a small pocket volume of 300 pages) for a I present to one just verging to manhood, whether a 6 BY KEY & BIDDLE. nke?v\« kapprcntice' or a son : and *uch a book as is hat not ™i' not on»y looked at, but looked into, and come famm£°n J^£* but daily ; ti" its contents be- come tamihar.—Chr. Spectator. lAlT* tha\ Bnould be possessed by every young man aayVv. PoT" l° ^ ^ Ma"'8 °™ Vok.-Vu". YOUNG LADY'S OWN BOOK, a Manual ot Intellectual Improvement and Moral De- portment By the author of the Young Man's Own Book. Messrs. Key & Biddle, of this city, have published a very neat little volume, entitled the Young Lady's Own Book. Its contents are well adapted to its useful pur- pose.—JVational Gazette. The Young Lady's Own Book seems to us to have been carefully prepared, to comprehend much and vari- ous instruction of a practical character, and to corre- spond in its contents with its title.—Young Man's Ad- vocate. The Young Lady's Own Book, embellished with beautiful engravings, should be in the hands of every young female.—Inquirer. All the articles in the Young Lady's Own Book are .of, a useful and interesting character—JV. Y. Com. Adv. YOUNG MAN'S OWN BOOK, a Manual of Politeness, Intellectual Improvement, V and Moral Deportment, calculated to form the character on a solid basis, and to insure respectability and success in life. Its contents are made up of brief and well-written essays upon subjects very judiciously selected, and will prove a useful and valuable work to those who give it a careful reading, and make proper use of those hints which the author throws out.—Boston Trav. We cheerfully recommend a perusal of the Young Man's Own Book to all our young friends, for we are convinced that if they read it faithfully, they will find themselves both wiser and better.— The Young Man's Advocate. In the Young Man's Own Book, much sound advice upon a variety of important subjects is administered, and a large number of rules are laid down for the regu- lation of conduct, the practice of which cannot fail to insure respectability.—Saturday Courier. (CLASSICAL LETTER WRITER, consist- S ing of Epistolary Selections, designed to improve Young Ladies and Gentlemen in the art of Letter Writing, and in those principles which are necessary for respect- ability and success in life. With Introduc- tory Rules and Observations" on Epistolary Composition. By the author of the Young Man's Own Book. Illustrated with two beautiful engravings. TODD'S JOHNSON'S DICTIONARY OF THE ENGLISH LANGUAGE: to which is added a copious Vocabulary of Greek, Latin, and Scriptural proper names, divided into syllables, and accented for pronuncia- tion. By Thomas Rees, LL. D, F. R. S. A. In a pocket volume, same size as the Young Man's Own Book, illustrated by a likeness of Johnson and Walker. The editor states that " in compiling the work he has endeavoured to furnish such an epitome of Mr.ToddIs enlarged and valuable edition of Dr. Johnson s Diction- ary as would enable the generality of personsU, tin- demand the most approved American and English authors and to write and speak the language with oro riot'y and elegance. The most correct definitions hive been given in a condensed form, and especial care foi« hern taken to indicate the classical and fashion- able pronunciation of every word." The style of print- in" ij really very handsome; and the embellishments. consisting of an engraving of Johnson and another of Walker, enhance the value of the edition. It is neatly bound, and would be an ornament to the study of any young lady or gentleman, while the traveller, on his summer tour, would find it an appropriate companion for his guide book and Stage Register.—Boston Traveller. This really beautiful and useful little work should be possessed by all who wish to spell and write the English language correctly. The publishers have ren- dered it so attractive in its appearance as to be an or- nament to the parlour centre table. It will add very little weight to the trunk of the traveller, and will often relieve him from painful embarrassment.— U. S. Gazette. This is the age of improvement. The simple ele- ments of education so long lying in forbidding print and binding, are now appearing as they ought, in the finest type and most beautiful and ornamental form. The Pocket Dictionary published by Key and Biddle deserves to be commended to the public generally, not pnly for the beauty of its execution, but for the intrinsic merit it possesses.—Charleston Courier. This beautiful little Dictionary should be the com- panion of every young lady and gentleman when read- ing or writing, whether at home or abroad.—JV. Y. Commercial Advertiser. MRS. SOMERVILLE'S CONNEXION OF THE PHYSICAL SCIENCES. The style of this astonishing production is so clear and unaffected, and conveys with so much simplicity so great a mass of profound knowledge, that it should be placed in the hands of every youth, the moment he has mastered the general rudiments of education.— Quarterly Review. A BOOK FOR MOTHERS. Aids to Mental Development, or Hints to Parents, being a System of Mental and Moral Instruction exemplified in Conversations between a Mother and her Children; with an Address to Mothers. By a Lady of Philadelphia. To know how to interest and expand the mind of a child with the lessons of wisdom—to impart knowledge in such a manner as at once to gratify and excite a thirst for it, is an acquisition possessed by very few ; but it is an acquisition indispensable to the right dis- charge of the duties of n parent. Many must be the hours of vacancy, or mischief, and most generally the latter, of the child whose parents have not the faculty of alluring him to knowledge and virtue, and convert- ing the pains of affliction into pleasure: and he who contributes any thing towards aiding them to discharge the duties devolving on them, deserves the gratitude of the public. We have before us a book in this depart- ment, entitled Aids to Mental Development, or Hints to Parents; just issued from the press of Key Sc Biddle of this city. It is in the form of a familiar con- versation between a mother and her children ; in a style delightfully natural, affectionate, and easy. The topics selected for discussion are those with which pa- rents of intelligence and piety would wish to make their children familiar; and the manner in which they are discussed is happily adapted to nurture the growth of both the intellectual and' the morul powers.—Chris- tian Gazette. As the subject of education is one of great impor- tance, and is beginning t<> be felt as such, by many who have hitherto bestowed upon it too little consideration, we cannot doubt that this work will meet with a ready sale, and extensive circulation ; nnd we can sincerely recommend it to the earnest and careful attention of all parents who have young children.—Saturday Cou- rier. AUTOBIOGRAPHY OF JOHN GALT, ESQ. ." I will a round unvarnished tale deliver." A work of commanding interest; its every page is an illustration of the remark,—that the romance of real life exceeds the romance of fiction. This is de- cidedly the happiest effort Mr. Gait has made.—JVeto Monthly Magazine. Mr. Gait's book will be read by every class of read- ers. It is a work full of interest and amusement, abounding in anecdotical recollections, and every- WORKS RECENTLY PUBLISHED where interspersed with the shrewd and searching ob- servations for which the author has been always dis- tinguished.—Saturday Courier. To our readers we cheerfully commend the book as amusing and instructive : it is full of interesting mat- ter, and as an autobiography will rate with the best of the day.—Philadelphia Gazette. It is full of striking illustrations of the remarkable character of its author; and for the mind disposed to study the individualities of our species, it contains much that will reward the investigation.—Commercial Herald. It is no less entertaining and much more useful than any one of his novels.—JVational Gazette. It is what it purports to be, " the autobiography of John Gait," and is interesting as presenting faithful illustrations of the singular character of the author— who is justly regarded as one of the best, as well as one of the most voluminous writers of the age.—Bos- ton Mer. Eve. Jour. THE BACHELOR RECLAIMED, OR CELIBACY VANQUISHED, from the French, by Timothy Flint.. It is a good lesson for those who are not married, and who deserve to be, for we do not hold that every bache- lor deserves a wife. Things of this kind (wives we mean) are meted out by Providence with an eye to re- ward and punishment; and a man may stand on such neutral ground in more ways than one, that a wife for either of the above providential ends, would be entirely out of the question ; but on either side of the line, there are some: and while men will sin, or must be virtuous, there will bo marrying; and if a man has any regard for his character, he will look to his stand- ing in this manner, and read this book of .Mr. Flint's translation.— U- S. Gazette. The main incidents arc connected with the history, of an inveterate bachelor—the worthy President of a Bachelor's Club—who, despite of himself, falls in love, against his principles, marries, and contrary to expec- tation is happy. This great revolution in sentiment is accomplished by the power of female charms, by an exhibition of the loveliness of female character, and by the force of reason—at least such are the conclu- sions of the author.—Philad. Gaz. It is, of course, a love story, and such an one as could only emanate from a French writer—light, enter- taining, and with an excellent moral. An inveterate bachelor is reclaimed—his hatred towards the female sex is changed into admiration, and eventually he marries. This change of sentiment in so determined a foe to matrimony, is a consequence resulting from an exhibition of female worth and excellence. The book should be read not only by bachelors, but by unmarried ladies—they may derive instruction from its pages.— Saturday Eo. Post. FRANCIS BERRIAN, OR THE MEXICAN PATRIOT. By Timothy Flint, Esq. This is an nil absorbing novel, we think Mr. Flint's best.—A". Y. American. TRIALS AND TRIUMPHS, comprising the Convict's Daughter, and the Convert's Daughter. There is no tragedy so affecting as that of private life. The writer of tins powerful volume has selected two subjects of very great interest. His observations upon men and manners, pictures of society, and sketches of character, are shrewd, just, and original.—Court Journal. These stories are written with croat taste and feel- ing, and the incidents are worked up with ingenuity and interest.—Bell's Messenger. FOLCHETTO MALASPINA, an historical Romance of the twelfth century, by the author of "Libilla Otlaletta," and translated from the Italian by Daniel J. Desmond, Esq. Th'i story is one of deep interest, and the translator has allowed nothing thereof to escape ; of the fidelity of the work wc cannot speak, having no access to the original; but as a novel, whether original or trans- lated, the work is good.— V. S. Gazette. It is emphatically a fanciful and engaging work, and no one can sit down to its perusal without being chain- ed by its magical influence, to an attention, which will be kept actively alive until the last chapter. In . this there is no exaggeration,—it is a novel to make ' the reader feel,—to have his curiosity and sensibilities awakened,—and to produce upon the heart those strik- ing impressions, which can only be excited by nature when portrayed by the enchanting descriptions of a master. The" scenes, the characters, the dialogues, aud the incidents, are so graphically sketched, and forcibly delineated, that we are compelled to admit that the production is of a more than ordinary character. Our space will not admit of pointing out particular beauties, or interesting passages; to the work itself we must refer our readers for a rich intellectual banquet, which is only to be obtained by its perusal. In dismissing this production, we remark that it is beautifully got up, and will form a graceful ornament to the most classical library.—Penn. Inquirer. From parts which we have read, of Mr. Desmond's translation, we have drawn a very favourable infer- ence concerning the execution of the whole; and we know that Malaspina's pages are held in high estima- tion by competent European and American critics. We ha\e noted in the Paris Revue Encyclopedique, a strong encomium on the works of this Italian novelist.— JVa- (tonal Gazette. TALES OF ROMANCE, FIRST SERIES. This is not only an uncommonly neat edition, but a very entertaining book ; how could it be otherwise, when such an array of authors as the following is pre- sented— The work contains Ali's Bride, a tale from the Per- sian, by Thomas Moore, interspersed with poetry. The Last of the Line, by Mrs S. C. Hall, an author who sustains a reputation which every succeeding produc- tion greatly enhances. The Wire Merchant's Story^ by the author of the King's Own. The Procrastinator, by T. Crofton Croker. The Spanish Beadsman. The Le- trend of Rose Rocke, by the author of Stories of Water- loo. Barbara S------, by Charles Lamb. A Story of the Heart. The Vacant Chair, by J. M. Wilson; and the Queen of the Meadows, by Miss Mitford. This volume has no pretensions to the inculcation of mawkish sensibility. We have read every word of it, and can confidently recommend it to our friends.— Journal of Belles Lettres. TALES OF ROMANCE, SECOND SE- RIES. The Tales of Romance, which Messrs. Key Sc Biddle have just published, are altogether above the ordinary collections of the day. Every author included among the contributors to the volume, has acquired previously a distinct reputation in other works. Such names as Malcolm. RuK-oe, and others, will be sufficient to give an idea of the merits of these Tales. The story of Fazio, from whence is derived the tragedy of that name, is well and conclusively told. We shall present the best part of it soon, to the readers of the Intelligencer. —Daily Intel. ZOE, OR THE SICILIAN SAYDA. As an historical romance, embellished with the crea- tions of a lively imagination, and adorned with the beauties of a classic mind, this production will take a high rank, aud although not so much lauded as a Cooper or an Irving, he may be assured that by a continuance of his efforts, he will secure the approbation of his countrymen, and the reward of a wide-spread fume.— Daily Intelligencer. We do not call attention to this on account of any previous reputation of its author: it possesses intrinsic merit, and will obtain favour because it merits it. It is historical, and the name and circumstances are to be found in the records of those times. The plot is ably ronceived, the characters are vividly, and some are fearfully drawn.—Boston American Traveller. TRANSATLANTIC-SKETCHES, com- prising visits to the most interesting scenes in North Amelia, and the West Indies, with .Notes on Negro Slavery and Canadian Emigration. By Capt. J. E. Alexander, 4'2d Royal Highlanders, F. R. G. S. M. R. A. S. &c, author of Travels in Ava, Persia, &c. BY KEY & BIDDLE. P^ERS FROM THE NORTH OF EU- jdrew to the shades of private life, resigning the crown ROPE, or Journal of Travels in Holland, Denmark, Norway, Sweden, Finland, Rus- Sn- !?Urfia' and Saxony- By Charles B. Elliott, Esq. an^m^nVL^T6 remarkabIy Peasant tours which an intelligent gentleman, who has seen much of the world, is alone calculated to write-one of those pro d,UC,nTwhVh.,Ch en*ar,t]U: a"e.,tion and do not°fo,igue it and which we read from first to last with the agreea- nrew„T. !°n' that. We are eatl'"ine the information of very extensive travel easily, by our owu fireside.- London Literary Gazette. ITALY: WITH SKETCHES OF SPAIN AND PORTUGAL. 2 vols. 12mo. The above work is a series of letters writ- ten during a residence in those countries, be- tween forty and fifty years ago. One of the most elegant productions of modern lite- rature.—London Quarterly Review, 1834. Glowing with genius.—Gentleman's Magazine. Rich in scenes of beauty and life.—Atheneum. One of the most remarkable books that has appeared in our time.—Morn. Citron. His travels were performed and his journals written towards the end of the last century. Consequently, the scenes, the men, the events, the institutions of the old regime, are now revived for us by one of the most ac- complished observers and eloquent describers of his age, whose objects and composition were facilitated by all the advantages which a tourist and author could pos- sess or desire. His work is a precious antique, brought forward at a juncture when it may serve the best pur- poses of contrast, and enable the world to estimate the extent and variety of the changes which have happen- ed this century.—National Gazette. We doubt if there has been a book of equal merit or originality published for many years in England, or which will be sought with such aridity in this country. —Poulson's D. Adv. This is one of the most interesting works we have met with for many months. The style is chaste, lively, and graceful—flowing and sparkling like a silvery foun- tain over a pebbly channel.—Com. Herald. These sketches are by a master hand; they evince throughout high refinement, a quick and admirable per- ception of the beautiful in art and nature, and a mind rich in knowledge and instruction.—JV. Y. Am. JOURNAL OF A NOBLEMAN; being a Narrative of his Residence at Vienna, during Congress. The author is quite spirited in his remarks on occur- rences, and his sketches of character are picturesque and amusing. We commend this volume to our read- drs as a very entertaining production.—Daily Intel. We presume no one could take up this little volume and dip into it, without feeling regret at being obliged by any cause to put it down before it was road. The style is fine, as are the descriptions ; the persons intro- duced, together with the anecdotes, and in general the entire sketching is by the hand of a ma.-ter. Every- thing appears natural—there is no affectation of learn- ing—no overstraining—no departure from what one would expect to see and hear—all is easy—all graceful. —Com. Herald. MEMOIRS OF HORTENSE BEAUIIAR- NAIS, DUCHESS OF ST. LEU AND EX-QUEEN OF HOLLAND. No one of all those distinguished personages who oc- cupied so large a space in the world's eye, from their connexion with Napoleon, presents a story of deeper interest than the amiable and accomplished subject of these memoirs. Possessing all the grace and fascina- tion of manner, which so eminently characterized her mother, the Empress Josephine, she has a streng h and cultivation of intellect; an extent and variety of know- ledge and a philosophic fortitude, which the Empress never could boast. Unhappy in her marriage, she was vet a devoted wife and fond mother; and though gifted with every quality to adorn royalty, she willingly with she had embellished without a murmur.—Saturday Courier. ---- A DIGESTED INDEX OF ALL THE RE- PORTED DECISIONS IN LAW AND EQUITY, OF THE SUPREME COURTS OF THE STATES OF OHIO, INDI- ANA, AND ILLINOIS, with an Appendix, containing the Constitution of the United States, the Constitution of each of the States above specified, and the rules of their Supreme Courts; also the rules of practice in the Seventh Circuit of the United States, the Acts of Congress for the authentication of statutes and records in the several States, and an epitome of the Sta- tutes for the admission of attorneys to the bar, and for the execution and acknowledg- ment of deeds and other conveyances, in all of the western and south-western States. By James F. Conover, Esq. of the Cincin- nati Bar. A work of this kind was very much wanted by the profession, and they should tender Mr. Conover their thanks for the able manner in which he has executed his task, which was undoubtedly one of very great la- bour and research. It is a large octavo, beautifully printed on fine paper, and handsomely bound. One of the Profession. TO PHYSICIANS AND STUDENTS. ILLUSTRATIONS ~OF PULMONARY CONSUMPTION; its Anatomical Cha- racter, Causes, Symptoms, and Treatment; with 12 plates, drawn and coloured from nature, by Samuel George Morton, M. D., Physician to the Philadelphia Aims-House Hospital; Lecturer on Anatomy ; Member of the Royal Medical Society; of the Col- lege of Physicians and Surgeons of the University of New-York; of the American Philosophical Society; of the Academy of Natural Sciences of Philadelphia, &c. &c. The work is certainly a very beautiful one ; the litho- graphs are finely executed, and well coloured. They form a striking and interesting series of illustrations of the progress of this formidable disease, from its com- mencement, through its various morbid conditions, to its natural cure.—American Jour, of Med. Science. We think the work one which reflects much credit upon its author, and we can conscientiously recom- mend it to the members of the profession, as a source from which they may derive much valuable informa- tion.—Baltimore Med. and Surg. Jour. Its style and manner are as creditable to the author as its matter promises to be useful to the profession. Its paper and typographical execution do honour to the workmen and artists concerned; and its plates are among the finest lithographs our country has produced. On these several articles of testimony in its favour, we found our hearty recommendation of it to the pub- lic.— Lexington Med. Jour. Although, in a suitable notice of this valuable work, we are somewhat behind most of our contemporaries in point of tune, a sense of duty will not permit us to be a whit behind them in our commendation both of its design and execution.—Boston Med. Mag. It is with no ordinary degree of gratification that we present to the notice of our readers this valuable work of Dr. Morton. Such a work at this time, is to us as reviving ami as refreshing as a pure fountain would be to the parched and thirsty traveller of the deserts of Arabia, and it will do much to raise the standard of medical excellence in our sister city. We cannot re- frain from adverting to the accuracy and beauty of the coloured plates, which are decidedly the best that have appeared in this country; indeed the whole work is got up in a superior style, and reflects great credit upon the liberality of the publishers.—(/. S- Med- and Surg. Journal. F WORKS RECENTLY PUBLISHED FOX'S BOOK OF MARTYRS. A Uni- versal History of Christian Martyrdom: from the Birth of our Blessed Saviour to the Latest Periods of Persecution. Origi- nally composed by the Rev. John Fox, A. M., and now corrected throughout: with copious and important additions relative to the Recent Persecutions in the South of France. In 2 vols. 8vo., beautifully printed on fine and remarkably strong paper. Being the only complete and unmutilated edition of this work ever presented to the Ameri- can public. Embellished with a Portrait of the venerable Fox, and sixty Engravings illustrative of the sufferings of the Martyrs in all ages of the world. THE SPIRIT OF LIFE. A Poem, pro- nounced before the Franklin Society of Brown University, Sept. 3, 1833. With other Poems. By Willis Gaylord Clark, Esq. . We hope Mr. Clark may find sufficient inducements to place before the public, in a more accessible form than that in which they are now scattered through the pe- riodicals of the day, more of the creations of his fancy, breathing as they do the fervour of moral purity, as well as chastened and beautiful poetry—we do not hesi- tate to say they will be most highly acceptable. The anonymous productions of his pen have long attracted the highest praise, and it is high time that he should, in his own person, reap the laurels he has so well earned, and boldly challenge a rank among the best of the American poets.—JV. Y. Mirror. The " Spirit of Life" is a clustering of many of those beauties, which all, who admire poetry, have already seen and applauded in the different productions of Clark's gifted mind.— U. S. Gaz. This poetry is of no common order. The author beau- tifully describes the Spirit of Life as pervading all Na- ture, and triumphing over the power of death.—Epis- copal Recorder. The " Spirit of Life" is an essay of sound morality, in the guise of smooth and easy versification. It aims by graceful numbers to better the heart; to teach it contentment here below.—Poulson's D. Adv. THE CELEBRATED BLUE BOOK. A register of all officers and agents, civil, military, and naval, in the service of the United States, with the names, force, and condition of all ships and vessels belonging to the United States, and when and where built; together with a correct list of the Presidents, Cashiers, and Directors of the United States' Bank and its Branches, to which is appended the names and compen- sation of all printers in any way employed by Congress, or any department or office of Government Prepared at the Department of State, by William A. Weaver. A Senator in Congress—we believe it was Mr. Leigh of Virginia—pronounced the said Blue Book—which heretofore, by the by, has been a sealed volume to the public at large, and only accessible to members of Con gress; the most significant commentary extant on the Constitution of the United States. And in one sense it is indeed so: for it exhibits the Executive, or pa- tronage and office-dispensing power, in a light that may very well make one tremble for the independence of the other branches of the government. As a book of warn- ing, therefore, not less than as a book in which much and various information is to be found, concernini; the practical operation and agents of the government, we commend this publication to public notice. We do not know that better service could be rendered the country than by the transmission to every county town in the Union, of some copies of this authentic Record, in or- der that farmers and others might see for themselves the mighty array of Officers, Agents, Postmasters, Con- tractors, &c. &.c, which constitute the real standing army of the Executive.—JV. Y. American. Messrs. Key & Biddle have published an edition of the Blue Book. It should be in the hands of every voter in the United States. It is a fearful account of execu- tive patronage.— U. S. Gazette. MEMORANDA OF A RESIDENCE AT THE COURT OF LONDON. By Rich- ard Rush, Envoy Extraordinary and Minis- ter Plenipotentiary from the United States ot America; from 1-117 to 1925. Second edition, revised and enlarged. THE PIECE BOOK, comprising choice spe- cimens of Poetry and Eloquence, intended to be transcribed or committed to inemorv. OBSERVATIONS ON THE CHARAC- TER AND CULTIVATION OF THE EUROPEAN VINE, during a residence of five years in the vine-growing districts of France, Italy, and Switzerland, by S. I. Fisher, to which is added, the Manual of Swiss Vigneron, as adopted and recom- mended by the Agricultural Societies of Geneva and Berne, by Mons. Bruin Chapj pi us: to which is superadded, the art of wine-making, by M. Bulos, member of the Institute of France. CELEBRATED SPEECHES of Chatham, Burke, and Erskine; to which is added the Argument of Mr. Mackintosh in the case . of Peltier. Selected by a Member of the Bar. Much is gained in richness and energy of expression^ j and fertility of thought, by the frequent perusal of the masterpieces of rhetoric. Historical knowledge too, if derived from them, vivified by the spirit of debate and indignant exposition of wrong. Some of the speeches ] in this acceptable collection relate to American affairs and character—we mean that of Burke on American Taxation, and those of Chatham which burst from bu soul of fire. The selection is judicious, and the bootf indispensable for the library of every citizen who wouM ' be a public speaker.—JVational Gazette. The frequent reading of such selections from such masters, cannot but prove advantageous to the young men of this country, where, more than in any oilier, dependence will be placed upon the power of eloquence; and it is well that good models should be furnished to those who do, or seek, thus to sway the public mind. Bring along the great truths of the argument in a cap- tivating style, and it will soon be found that even the most uninformed will strike into the current of the ad«, dress, and be carried along thereby.— V. S. Gazette. JL"' Among the great men in the intellectual world, who have astonished and delighted, charmed and instructed mankind, by the splendour, power, and magnificence of.. their oratory, none stand higher than Chatham. Burke,■", Erskine and Mackintosh. The speeches contained in,,, this volume are splendid specimens of rich, ornate, pow- erful, and argumentative oratory, and no one possess- q, ing in the least dcgiee a love for intellectual grandeur,.^ can read them without feeling his heart glow with ad-_, miration, and have his soul animated with a zeal the liberty of all mankind.—Penn. Inquirer. This volume contains some of the speeches of ihesici great masters of English Eloquence—speeches whkftj.\Y whether we refer to the momentous character of their- topics, their power of thought and display of learning, ' or their charms of style and graces of diction, will server! as models for public speaking, and sources of instruc- r tion. political, intellectual and moral, to all future ages.—Charleston Courier. , -. IRISH ELOQUENCE.—The Speeches of* the celebrated Irish Orators, Phillips, Cur-n 10 BY KEY & BIDDLE. ran, and Grattan; to which is added, the it i« extremely i powerful Appeal of Robert Emmett, at the? ^8t ***» in .lhri' close of his trial for high treasr- «-'-- 1 <".<* »r« continual ed by a Member of the Bar. f Tr?«£bove " ork forms a complete and un ' Irish oratorv. T« >vm m.mw .<.t - 4 scnooi .a.nd J?c.arce,y 'ess does'i't 'reconunond'Ttsel'/to TI.e Speeches of Phillips, Curran, Grattan, and Em- tg'&s&y^x!*a ncat octav°voiume ^ ,JiitS«f ireCessary for us to 8a>' a"y thine as to the \voStLnoraSPI°ndid di.?plays 0f eI°1"«n«. which or, th"P 8" """""-talityon the above named ora- n~,i, i. InTtB ttre we" known, and wherever these p.eclios have been read, they have been admired. I he volume ,s neatly " got up," the paper is good, the ; - is clear bold and legible, and the binding is sub- .antial and durable.—Daily Intelligencer. TO TEACHERS AND PARENTS. 'JNNOCK'S IMPROVED EDITION OF DR. GOLDSMITH'S HISTORY OF ENGLAND, from the Invasion of Julius Ctesar to the Death of George II., with a continuation to the year 1832 : with Ques- tions for examination at the end of each section; besides a variety of valuable in- formation, added throughout the work, con- sisting of Tables of Contemporary Sove- reigns and Eminent Persons, copious Ex- planatory Notes, Remarks on the Politics, Manners, and Literature of the Age, and an Outline of the Constitution. Illustrated with Thirty Engravings on Wood. First American, corrected and revised, from the Twenty-third English edition. Messrs. Key & Biddle have published a beautiful edi- on of the History of England, in one large duodecimo, y Pinnock, who professes to have (Goldsmith's work as s foundation. We have been looking through the plume with that degree of care which we think a hool book deserves, and have arrived at the conclusion lat th" author of this volume has done a service to the mug, in presenting such a work for their use. Mr. intiock has avoided the errors peculiar to Goldsmith, ho really did not always consider that his work was itended for the young, and has corrected some of the Use glosses and misstatements which disfigure many ristones of our father land. The arrangements of the rark are highly suitable to schools, and the tables at he close of the chapters, of contemporary sovereigns, vill be exceedingly useful in giving the scholar and enc-ral reader a proper knowledge of the exact rela- ion which the portion of history he has been attcnd- ' to, has to that of other countries. The questions re copious, and well placed, and we may confidently ecommend Pinnock's Goldsmith's England, to the at ention of parents and teachers. One word upon the printing and binding of this book -they are well done, the paper is good, and the nume- ous engravings illustrating the text show well. This is is it ou"ht to be—children dislike badly-printed books. }ne common school book, well executed in its median- caf parts, is worth half a dozen got up to be sold cheap. Me sneak from a knowledge of these things. A school nok worth printing at all, is worth printing well. This is a history of the mother country, adapted to ohnols • and it is admirably suited to that purpose. We Resume its unquestioned merits will procure it a uni- versal rcCcption in our seminaries.— JVational Banner. ' This volume is intended not only for the general -Jllr but for the special use of schools. We have ™ined the book, and must say we like the arrange- ,xa, H,Ccedingly. We commend it to the particular neni e* jnBtructor9 and others.—Commercial Herald. m port ant to teachers to possess the arduous duties, for without system ually liable to trouble and vexation ; if all Khool books were as well adapted to practice as Pinnock's Goldsmith, the art of teaching would be much simplified. The work recommends itself to every fami- ly, and will be found the best history of England irr an abridged form extant. The number of London editions is a sufficient guarantee of its value.— Poulson's Daity Advertiser. The elegance and simplicity of Goldsmith's style— his graphic powers of description—his tact in selecting the most striking incidents for his narrative, have made his history of England much coveted by young persons. Some inaccuracies in his statements, calculated to mis- lead inquiring minds—some defects in chronological arrangement, and other objections, however, existed against the work, and its usefulness was much im- paired in consequence. These are all obviated in the edition now published, which has been carefully ex- amined, and gleaned of its principal imperfections. Besides this improvement, there are sets of questions attached to each chapter, which make it particularly desirable for schools.—Saturday Courier. From S. JONES, A. M., Principal of the Classical and Mathematical Institute, Philadelphia. I have attentively examined Pinnock's improved edi- tion of Dr. Goldsmith's History of England, published by Messrs. Key &. Biddle, of this city, and am impress- ed with its excellence. I have no hesitation in ex- pressing my full approbation of the work, with my be- lief that it will receive a liberal patronage from an enlightened community. Ulh Mo., 1S34. We consider Pinnock's edition of Goldsmith's Histo- ry of England, as the best edition of that work which has yet been published for the use of schools. The tables of contemporary sovereigns and eminent per- sons, at the end of each chapter, afford the means of many useful remarks and comparisons with the history of other nations. With these views, we cheerfully re- commend it as a book well adapted to school purposes. Friends' Academy, Philad. J. II. Black, Tnos. Collins, James Crowell, J. B. Walker, S. C; Walker, T. H. Wilson, J. MlDEIRA, Wm. Mans, W. Marriott, C. B. Treoo, Uriah Kitchen, Tnos. Eustace, John Haslam, W. CtlRRAN, I. Stockdale, S. H. Reeves, I. Haymar, W. B. Rose, Ciias. Mead, Benj. Mayo, John M. Keaggy, Seth Smith, El. Fouse, J. E. Slack, Joseph R. Eastbi:r!», A. Stephenson, Saml. Jones, Wm. A. Garrioues, M. SOULB, CnAS. Henry Alden, John Eustace, Benj. C. Tucker, High Morrow, Wm. .M< Nun, E. H. Hubbard, R. Lake, JonN Webb, John Ord, Svml. Clendinin, D. R. Asiiton, J. O'Conor, Sec'y. to the Philadelphia Associa- tion of Teachers. Joseph Warren, Thomas Conrad. Gentlemen—I have long looked (but without effect, till now,) for a reading book combining at once, inte- rest, chasteness of diction, and valuable historical in- formation, placed in so enticing a form as to induce the student to read it for itself and the facts it contains. My long experience has taught me, that without inte- rest the pupil will not trouble himself to understand, and without understanding 'tis in vain to teach, either for improvement in the science of reading or for infor- mation. Happily, teachers have in Pinnock's Gold smith's History of England numerous requisites un- known to the best of its predecessors. Yours, L. BICKNELL. We fully concur in the above. Wm. ROBERTS. B. N. LEWIS. L'ABEILLE, pour les Enfans; ou, Lecons Franchises; lere partie; a l'usage des ecoles. THE BEE, for Children; or, French Lessons; Part First; for the use of Schools. This work has been carefully prepared by a teacher of Philadelphia, and pruned of those objectionable ex- pressions so common in books of this kind. — WORKS PUBLISHED BY KEY ifc BIDDLE. A TREATISE ON THE ELEMENTS OF ALGEBRA. By Rev. B. Bridge, D. D. F. R. S., Fellow of St Peter's College, Cam- bridge, and late Professor of Mathematics in the East India College, Herts. Revised and corrected from the sixth London edi- tion. In this work the hitherto abstract and difficult sci- ence of Algebra is simplified and illustrated so as to be attainable by the younger class of learners, and by those who have not the aid Of a teacher. It is already- introduced into the Univetsity of Pennsylvania, at Philadelphia; and the Western University, at Pitts- burg. It is also the text book of Gummere's School at Burlington, and Friends' College at Harvard, and of a great number of the best schools throughout the United States. It is equally adapted to common schools and colleges. Philadelphia, March 7th, 1833. Bridge's Algebra is the text book in the school under my care; and I am better pleased with it than with any which I have heretofore used. The author is very clear in his explanations, and sys- tematic in his arrangement, and has succeeded in ren- dering a comparatively abstruse branch of science, an agreeable and interesting exercise both to pupil and teacher. JOHN FROST. We fully concur in the opinion above expressed. Charles Henry Alden, Joseph Warren, J. O'Conor, Secretary to Saml. Ci.endinin, the Philadelphia Asso- S. H. Reeves. ciation of Teachers. University of Pennsylvania, March 30, 1?33. Gentlemen—In compliance with your request, that I would give you iny opinion respecting your edition of Bridge's Algebra, I beg leave to say, that the work ap- pears to me to be well adapteil to the instruction of students. The arrangement of the several parts of the science is judicious, and the examples are numerous and well selected. Yours, respectfully, ROBERT ADRAIX. We concur fully in the opinion of Bridge's Algebra as expressed by Dr. Adrain. J. Haym vr, Hugh Morrow, Wm. McNain, Oliver A. Shaw Seth Smith, Saml. E. Joke<:, Jno. M. Keaooy, Thomas Conrad Tnos. Collins, J. E. Slack, C B. Trego, J. B. Walker, John Haslam, W. Curran, B. N. Lewis, John Stockdale, W. B. Rose, Benj. Mayo, J. H. Black. GUY'S ELEMENTS OF ASTRONOMY, AND AN ABRIDGEMENT OF KEITHS NEW TREATISE ON THE GLOBES. Thirteenth American edition, with addi- tions and improvements, and an explanation of the Astronomical part of the American Almanac. Illustrated with eighteen plates, drawn and engraved on steel, in the best manner. A volume containing Guy's popular treatise of As- tronomy, and Keith on the Globes, having been submit- ed to us for examination, and carefully examined, we can without any hesitation recommend it to the notice and patronage of parents and teachers. The work on Astronomy is clear, intelligible, and suited to the com- prehension of young persons. It comprises a great amount of information, and is well illustrated with steel engravings. Keith on the Globes, has long been recognized as a standard school-book. The present edi- tion, comprised in the same volume with the Astrono- my, is improved by the omission of much extraneous matter, and the reduction of size and price. On the whole, we know of no school-book which comprises so much in so little space, as the new edition of Guy and Keith. Thos. Eustace, John O'Conor, Secretary to John Haslam, the Philadelphia Associa- W. Curran. tion of Teachers. Saml. CLENDfNtN, B. N. Lewis, B. H. Reeves, Charles Henry Ai.den, 12 John Stockdale, W. B. Rope, Charles Mead, Behj. Mayo, Hugh MorroWi J. II. Black, I. Haymar, Jno. M. KEAonT, S. C. Walker, J. B. Walker, J. E. Slack, Joseph R. Eastbcrn, Benj S. Tuckbr, J. H. Brown, John Ord, Seth Smitii, Wm. Roiierti, T. H. Wilson, Joseph Warren, Thos. Collins, Wm. Mann, Rial Lake, Mm. Marriott, C. B. Trboo. THE RELIGIOUS SOUVENIR, a Christ j mas, New-Year, and Birthday Present, fo 1835—edited by the late G. T. Bedell, D.I Rector of St. Andrew's Church, Philade phia. It contains eight splendid Engraving on Steel, as follows: 1. Mrs. Wolff, engraved bv Ellis, from a painting by Lawrence, 2. Vignette, engraved by £l!is. 3. Sunday Morning, engrave.) by Tucker. 4. Destruction of Sodom, engraved by Sinilie. 5. The Invasion, engraved by Nea;le. 6. Frederick and Ellen, etgraved by Lawson. 7. Early Piety, enured tv Ellis. 8. Calomel, the Christian Indian, engraved by Tucker. As the Souvenir for 1^35, contains the last of the li crary labours of the late Kcv. Dr. Bedell, the voluu must possess a melancholy interest for the numeral friends of that eminent clergyman, and an addition. value in their estimation. The obituary notice fro the pen of the Rev. S. H. Tyng, is eloquent, feryeri and appropriate. The engravings are eight in n urn hi some of which are very superior, and all very crcditat specimens of the fine arts.—Pa. Inq. and Courier. We have just received Key & Biddle's Religious go venir for 1.^5—which, certainly, in the highly finish style of its binding, and the extreme beauty of itU: graving*, stands this year, as it did last, first amodvl brethren, and is fairly entitled to compete with ItieK of its elegant rivals in England. The engravings!! eight in number, finely executed in line, and exhibit" extreme felicity in the choice of subject. Lady Geort ana Wolff—the wife, we believe, of the celebrated Jei •) ish Missionary, is one of those exquisite personatio i by Lawrence, where soul alike seems breathing in ti • altitude and features; and the fine eye appears tobea with the intelligence of thoucht. The Destruction Sodom is one of those astonishing pictures of tMMaj 1 tin school, where crowds of palaces and grovesof e 1 Inmns are grouped together, and are seen tumbAf) 1 on fearful ruin. It has many features in rommotMH. j Dnnby's openins of the Sixth 3oal, and ,s"e"e?WHI 1 by James Smilie. Sunday Morning is a lovely >Vllsn like group, full of that expressive poetry of life Wjsi painters delight to portray, and which every Ipfet unsophisticated nature takes pleasure in witMsjaif This plate is engraved in a manner highly cretrtyab Early Piety is another gem of American art, aad ( rives extraordinary effect from the masterly barifl George B. Ellis. The literary character of the work certainly much better than we usually get in such pi v iluctions: it has not at all suffered in this respect fn the lamented death of the editor.—JV. Y. Com. Ado. The reading contents we think much superior to the articles so i number for 1K34. Among the contributors, in addition to the late edi . j Dr. nedell, we notice the initial, of Mia Gould. Mm WeaJbndge, W. & '' Clark, Mrs. Sigourney, and others of equal celebrity in the litem? wo f 1 The obituary notice of Dr. Bedel), and the poem to his memory, are j rremely well written. The Invasion, by Mrs. Signuroey, and the Cilul ' by M , are deeply interesting sketches, but scarcely more eu( profitable than various other articles from other writers. Th gether possesses strong attractions, and will no doubt be early by the reading community. It is needless to add that the " ecu'ion and binding, are of the most finished character.—, We have only time at present to notice its appearance, *J ippearsto as to correspond entirely both in the beauty of its the value of its articles, with the preceding volumes. The I paration was the last literary labour of its lamented editor, > melancholy interest, and, in connection with its intrinsic merit, cure for it at once the favour of the public—Epii. Arc The Religious Souvenir for 1S3.1, surpasses any former popular series. Neither pains nor expense have been spared in and it is gratifying to find that the late lamented Dr. Bedell b: supervision of the present volume, having arranged and apy.v tents before his death. The embellishments are truly superb, annual, presented for the patronage of this community, ever strong claims as the Religious Souvenir, and II is gratifying mand has been heretofore so great as to induce a continoauce, permanence to the publication.—Petition's Daily Ado. The Religious Souvenir for 1835 is as rich in pictorial _ literarv contributions, as its predecessor. One story. The Cw Christian Indian, is worth the price of the whole work—it is wi in a work projected by Btdtll, and carried on by that distingl— until he ceased to have rfirref connexion with thinrs of earaV >/,.„ *. nt rAA th* t.vnuritmm nf 4*,aII,. —____P.. .__.... «. •ML LIBRARY OF MEDICINE a. ^=r NATIONAL LIBRARY OF MEDI ■J ° 3nidio3vv jo Aavaan ivnouvn M / ML LIBRARY OF MEDICINE D3w jo Aavaan ivnouvn )&' * VN t MAI LIBRARY OF MEDICINE "> NATIONAL LIBRARY OF MEDICINE *o -J — V^f ^ s SS\ \ ? / i i^^x,,/ .8- <.. /^-^ 3NiDia3w jo Aaviian ivnouvn X^X I '" 3NIDia3W JO AHVllen IVNOUVN NATIONAL LIBRARY OF MEDICINE r \ /"' ^ 3NIDia3W JO AHVM9I1 IVNOUVN d: A> X*' #■ f %-, N n > ' X «> X- i NATIONAL LIBRARY OF MEDICINE n 7SN ! /^-^f l/i& ]3W JO AaVrJolT IVNOUVN X W-X A NAL LIBRARY OF MEDICINE > x X. 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