".-,•' ■■■■• ■>•<• •'■■' vt "-.') >' A TREATISE ON THE PRACTICE OF MEDICINE. .JOHN EBERLE, M. D., professor of materia medica and botany in thk ohio medical college; member of the american philosophical society; of the academy of natural sciences of Philadelphia; and corresponding member of the medico-chirurgical society of berlin, in prussia, &c. &c. ,,'"2^z .— -*<. ^^m IN TWO VOLUMES. VOL. I. THIRD EDITION, REVISED AND ENLARGED, -.-jy / GRIGG & ELLIOT, 9 NORTH FOURTH STREET. 1835. WB Elf* l?35 v. I Entered according to the act of Congress, in the year 1831, by John Eberle, M. D., in the clerk's office of the district court of the United States, in. and for the eastern district of Pennsylvania. Philadelphia: T. K. & P. G. Collins, Printers, No. 6, George Street. TO GEORGE M'CLELLAN, M. D., PROFESSOR OF SURGERY IN THE JEFFERSON MEDICAL COLLEGE, &C. &C, THIS WORK IS INSCRIBED, AS AN ACKNOWLEDGMENT OF THE HIGH REGARD ENTERTAINED FOR THE POWERS OF HIS MIND, AND THE GENEROUS SENTIMENTS OF HIS HEART, BY HIS OBLIGED FRIEND, THE AUTHOR. PREFACE. In the composition of this work, an effort has been made to exhibit a distinct view of the essential phenomena and principles pertaining to the various subjects which it em- braces, with an especial endeavour to avoid the extremes of unsatisfactory brevity on the one hand, and of fatiguing prolixity of detail and discussion on the other. With the exception, therefore, of a few instances in the introduc- tory portion of the work, the author has indulged but little in controversial discussion and general speculation. His object has been, to give a digest of facts and established principles, rather than of opinions and points of disputation. He has not, however, failed to give an exposition of those pathological and therapeutic principles, which appeared to him fairly deducible from the particular phenomena brought under consideration; and wherever his own experience and reflections have led him to differ from others, he has freely, though he trusts with becoming deference, stated his senti- ments. It will be perceived, that no general doctrine or system of pathology is exclusively or especially favoured in the following pages. Medicine, as it is now generally culti- vated, is strictly eclectic. The judicious and unprejudiced physician will neither condemn, nor adopt unreservedly any of the leading doctrines advanced in modern times. He will see something to admire and embrace in the systems of Brown, of Cullen, of Darwin, of Broussais—and even of VI PREFACE. the fanciful Hannemann; although when offered to his ac- i ceptance as doctrines of universal application, he may very reasonably refuse his assent. It will be seen also, and perhaps by some regarded as a defect, that no formal classification has been adopted in the arrangement of the work. Nevertheless, the order that has been observed in the succession of the various subjects, is probably as natural as that obtained by any of the modes ' of systematic arrangement usually pursued in works of this i kind. It is now generally, and very justly believed, that the artificial, classific, ordinal and specific distinctions of nosology have an unfavourable influence on the progress of comprehensive and philosophical views in pathology. The primary elements of disease, like those of matter, are proba- i bly but few in number. A few elementary modes of morbid action (if the expression may be used) modified in their general results or phenomena, by different grades of inten- sity, modes of combination, and the structures implicated, ( constitute the fundamental morbid conditions, of which the phenomena by which diseases are described, are merely the external manifestations. It is here that the unfavourable tendency of nosological distinctions mainly exists. Instead of leading the student to contemplate the morbid symptoms as the mere external expressions or signs of disease, modi- fied by various accidental circumstances, and especially by the structures chiefly affected, the artificial divisions of nosology are apt to lead him to regard the groups of symp- toms, usually associated, as so many distinct essences, pos- sessing fixed and specific peculiarities of character. To these objections, the arrangements founded on the particular structure primarily implicated in the disease, are not liable. It must be admitted, however, that correct and philosophical as such a classification may appear to be in theory, the attempt to reduce it to practice is attended with many very serious difficulties. Nevertheless, should another 1 PREFACE. Vll edition of this treatise be called for, it is the intention of the author to arrange its materials upon this plan of classifi- cation. It is not improbable that various errors may have escaped the author's attention in the course of the work; but he has no apologies to offer for any defects it may be found to possess; and he sends it into the world, in the hope, that with whatever blemishes and deficiencies it may be charge- able, it will be found a useful compilation of facts and prin- ciples in pathology and practice. ADVERTISEMENT TO THE THIRD EDITION. It will be perceived, that the arrangement promised in the first and second editions has been adopted in the pre- < sent one. That it may be obnoxious to objections in some of its details, cannot be doubted; but the general scheme, j it is believed, will be acknowledged to accord better with the present state of pathological science, than the more ; artificial and complicated classifications repudiated in the Preface. Considerable additions have been made in the present \ edition. The subjects of pneumo-thorax, infantile convul- . sions, pericarditis, and hysteritis, omitted in the first, are introduced in this edition; and the chapter on the general A pathology of fever has been entirely re-written. To these chapters are now added those on diagnosis and cholera asphyxia; the latter being placed, from an accidental cause, 5 as an appendix to the second volume. Many pathological and therapeutic observations, also, have been introduced throughout the work; and no inconsiderable number of typographical errors, as well as errors of language, which had escaped the author's attention, have been corrected in " the edition now offered to the public. CONTENTS OF VOLUME I. PRELIMINARY OBSERVATIONS ON THE PATHOLOGY AND ETIOLOGY OF FEVER. CHAPTER I. Page Of the Pathology of Fever in General, - - - 13 CHAPTER II. Of the Causes of Fever. Sect. I. Of Predisposition, and Predisposing Causes, - 39 Sect. II. Of the sources of Morbific Causes, and their General Character,.....42 Sect. III. Atmospheric Temperature, and its relations with the Animal System,.....44 Sect. IV. Of Miasmata,......50 Of the relations of Miasmata to the Animal Systsm, fyc.........59 Sect. V. Of Contagion,.......64 CHAPTER III. Of the General Course, Type, and Stages of Fever, 70 CHAPTER IV. On General Diagnosis, -.....77 -9©e- I.—GENERAL IRRITATIVE DISEASES OF THE BLOOD-VESSELS INDEPENDENT OF LOCAL INFLAMMATION. CHAPTER V. Of Intermitting Fever,......103 CHAPTER VI. Remitting Fever,.......128 Vol. I.—2 CONTENTS. Page CHAPTER VII. Yellow Fever,.....- - -146 CHAPTER VIII. Continued Fever,.......154 Sect. I. The Synochal Grade of Idiopathic Fever, or Sim- ple Inflammatory Fever, - - - - 158 Sect. II. The Synochus Grade of Idiopathic Fever, - - 163 Sect. III. Typhus,...... - - 179 -3©£H II.—GENERAL IRRITATIVE DISEASES OF THE BLOOD-VES- SELS, CONNECTED WITH OR DEPENDENT ON LOCAL INFLAMMATION. CHAPTER IX. Of Inflammation in General,.....199 CHAPTER X. Of the Phlegmasia; of the Alimentary Canal, and its Acces- sory Organs. Sect. I. Of Glossitis,....... go6 Sect. II. Of Tonsilitis,......_ 208 Sect. III. Of Parotitis,......-211 Sect. IV. Of Acute Gastritis, - - - - . -213 Sect. V. Of Chronic Gastritis, - - - _ -217 Sect. VI. Of Acute Enteritis, - - . -* - 223 1. Acute Peritoneal Enteritis, - - _ 224 2. Acute Mucous Enteritis, - - - 232 Dysentery, - - . _ . . i0 Sect. VII. Of Chronic Enteritis,.....247 Sect. VIII. Of Acute Peritonitis, - - 251 Sect. IX. Of Chronic Peritonitis, - 050 Sect. X. Of Acute Hepatitis*- - . . 0fiQ Sect. XI. Of Chronic Hepatitis, - iti Sect. XII. Of Splenitis, - oil CHAPTER XI. Of the Phlegmasia of the Nervous System Sect. I. Phrenitis, ----_:_' Sect. II. Arachnitis, - ~ * Sect. III. Cerebritis—(Ramollissemcnt du Cerveau.) - 298 CONTENTS. XI Page CHAPTER XII. Of the Phlegmasise of the Respiratory Organs. Sect. I. Pneumonia, - -.....302 Pleuritis,.......?"- Peripneumonia, ------ 305 Pneumonia Biliosa, ----- 306 Sect. II. Cynanche Laryngea,.....317 Sect. III. Cynanche Trachealis, - - - - - 321 Sect. IV. Acute Bronchitis,......334 Sect. V. Chronic Bronchitis,......339 Sect. VI. Phthisis Pulmonalis,.....350 CHAPTER XIII. Of the Phlegmasise of the Urinary and Genital Organs. Sect. I. Nephritis,........364 Sect. II. Cystitis, - - - - -' - - - 369 Sect. III. Chronic Cystitis, -.....372 Sect. IV. Hysteritis, -......375 Sect. V. Chronic Hysteritis,......379 CHAPTER XIV. Of the Phlegmasise of the Sanguiferous System. Pericarditis,......382 CHAPTER XV. Of the Phlegmasise of the Fibrous and Muscular Structures. Sect. I. Acute Rheumatism,......387 Sect. II. Chronic Rheumatism,.....398 Sect. III. Gout,........404 CHAPTER XVI. Of the Inflammatory Affections of the Eyes. 1. Catarrhal Ophthalmia, - - - - 418 2. Rheumatic Ophthalmia, - - - - 421 3. Purulent Ophthalmia, - - - - 422 4. Scrofulous Ophthalmia, - - - - 426 5. Syphilitic and Strumous Iritis, - - 431 CHAPTER XVII. Of the Cutaneous Phlegmasise.—Exanthemata. Sect. I. Variola,..... 434 Sect. II. Vaccina,..... xn CONTENTS. j Page Sect. III. Modified Small-Pox, - ... - 455 1. Varioloid Affections, - - - i°- % 2. Varicella,.....- 461 Sect. IV. Rubeola, morbilli,......464 Sect. V. Scarlatina, -......475 Sect. VI. Erysipelas,.......495 CHAPTER XVIII. Minor Exanthemata. Sect. I. Herpes, -------- 509 1. Herpes Phlyctenodes, - - - - 510 2. Herpes Zoster, - - - - -511 3. Herpes Circinatus, - - - - -514 4. Herpes Labialis,.....515 5. Herpes Preputialis, - ib. Sect. II. Pemphigus,.....- -516 Sect. III. Urticaria, ------- 523 Sect. IV. Miliaria,.......527 Sect. V. Lichen,.......-529 Sect. VI. Eczema,........533 Sect. VII. Erythema,.......537 Sect. VIII. Roseola,.......539 Sect. IX. Purpura,...... 540 CHAPTER XIX. Vascular Irritations with a flow of Blood. Hsemorrhages, - - - _ _ 545 1. Epistaxis, ______ 553 2. Hsematemesis, - 555 3. Hematuria, --.__. 559 4. Hsemoptysis, ------ 562 5. Menorrhagia, - - - - . -568 CHAPTER XX. Phlegmasise of the Lymphatic System. Phlegmasia Bolens, - 573 A TREATISE ON THE PRACTICE OF MEDICINE. A. PRELIMINARY OBSERVATIONS ON THE PATHOLOGY AND ETIOLOGY OF FEVER. CHAPTER I. OF THE PATHOLOGY OF FEVER IN GENERAL. The history of practical medicine consists of little else than a review of the doctrines which have successively risen and sunk again, concerning the nature and treatment of fever. Whatever other objects of interest or importance within the dominion of medical science may have attracted the attention of physicians, fever has at all times been viewed as presenting the most extensive and inviting field for observation and the exercise of ingenuity. It is in this department that observation and research have been most industrious in accumulating materials, and that hypothesis has luxuriated in her wildest exuberance. When, indeed, it is considered that the destroying angel has made his most desolating visitations under the form of febrile epidemics, and that in the long list of human maladies, fever occurs in perhaps nine cases out of ten, the paramount importance of this subject is strongly forced upon our convictions.* * " If we except," says Van Swieten, " those who perish by a violent death, and such as are extinguished by mere old age, and which are indeed few, al- most all the rest die either of fever, or of diseases accompanied with fever. We read in Pliny with what fear and trembling the Romans endeavoured to have 14 GENERAL PATHOLOGY OF FEVER. From a retrospective glance over the history of our science, we are forced to acknowledge that there is, perhaps, no subject which is more eminently calculated to humble the pride of human reason than this one. In relation to this subject, pathology has been in a continued state of revolution and instability. The human mind has been engaged with it for near three thousand years. Theories have risen and sunk agayi in a continued and rapid series of succession; each has had its hour "to strut upon Jhe stage," and its votaries to yield it faith; but the stream of time hasAherto overturned all these insubstantial, though often highly wrou^Pt fabrics. Has the mind then made no real advancement in relation to the pathology of fever? Are we now no nearer correct and rational views concerning this important subject, than were our forefathers. Has genius always wandered in idle quest, and brought back no substantial trophies from the regions of pathological speculation on this point? Far from it. Like the assymptotes 'of the parabola, the human mind is continually verging towards truth, although it may never reach it in relation to the essential nature of fever. There has probably never been a theory or doctrine promulgated on this sub- ject, which did not clear away some old rubbish, or bring to fuller view some of the relations of the phenomena it presumed to elucidate. The dreams of speculation have vanished; but the facts and correct principles which were necessarily mingled with them, remain as so much valuable treasure saved out of the wrecks of former systems. The mass of solid materials which has been thus gradually accumu- lated, has now in a great measure displaced those vague and hypo- thetical foundations upon which former doctrines in relation to this subject were constructed. Hypothesis is no longer tolerated in science. Philosophy does not acknowledge her as a legitimate ser- vant. The cyclus of her empire has gone by; and the genius of rational induction is now the only power under whose direction the votary of science presses forward to conquest in the fields of know- ledge. Like many other things which are at once obvious to the senses, and concerniug the existence of which almost every one can decide, fever does not admit of a strictly correct and unobjectionable defini- tion; since there is not a single symptom which is invariably present, and which can be regarded as absolutely essential to its existence. Boerhaave collected together, from a great number of authors, this universal disease—fever, appeased by their supplications in the temple of Fanum; and hence, perhaps it is, that fevers are called diseases by Hesiod, and that Horace calls all diseases simply fevers, when they rushed out of the box of Pandora— 'Post ignem aetherea domo Subductum, Macies, et nova febrium Terris incubuit cohors.'" Van Swietcn's Com. vol. v. p. 1. GENERAL PATHOLOGY OF FEVER. 15 all the symptoms which had been observed in fevers. He then struck from this list, all those symptoms which do not appear in all, but only in certain modifications of fever—retaining such only as by the common consent of authors and his own observations, were found to be present in every instance of fever. The result was, that only three symptoms were left standing—namely, a quick and fre- quent pulse—preternatural heat of the surface of the body, and a sense of cold or-chilliness in the commencement. But he might have gone farther, and struck from his list these symptoms also; for it is quite certain that casef»$f fever do occur in which there is nei- ther preternatural quickness and frequency of the pulse, nor an in- creased temperature of the surface of the body; nor is a sense of chilliness, though perhaps the most constant of all the febrile symp- toms, universally present in the initial stage of fever. Notwithstanding the great difficulty, or rather impossibility, of giving a strictly unexceptionable scientific definition oi fever, yet the train of phenomena which this state of disease presents under all its modifications—varying more or less in their concomitance and succession—offers, upon the whole, a character sufficiently distinct and definite for easy and certain recognition. Pathologists have divided fevers—according to the mode of their development—into idiopathic and symptomatic, and the propriety or impropriety of this division constitutes, at the present day, one of the most important, and warmly contested subjects in pathology. By the former class, are understood those fevers that are developed and sustained by causes, which produce a general morbid state of the system, independent of local inflammation or fixed irritation. Those who admit the existence of such fevers, suppose that the re- mote febric cause produces a deleterious impression on the sentient extremities of the part upon which it acts, which deranging function after function, according to the catenation of the organic sympathies, finally results in a state of general disease, characterized by the or- dinary phenomena of fever; or, as they presume, the remote cause may gradually change the healthy character of the circulating blood, which, acting as a morbific irritant on the heart and arteries, gives rise to febrile reaction. Many eminent pathologists, on the contrary, contend that such fevers can have no existence; and that all febrile excitement is purely symptomatic, and of course essentially and wholly dependent on a pre-established local irritation or inflammation. According to these views, the direct influence of the remote causes of fever is limited to the production of the primary local inflammation or irritation, the subsequent pyrexial phenomena being the result solely of this pri- mary local affection; in other words, the secondary and sympathetic excitement of the pre-established focus of irritation. At the head of those who advocate the exclusive symptomatic nature of fever is Broussais, who, whatever may be thought of his peculiar doctrines 16 GENERAL PATHOLOGY OF FEVER. in relation to this subject, has manifested a professional zeal, an^.^" activity and acuteness of intellect, which have justly placed him high among the " greater lights" of our profession. Not satisfied, how- ever, with the adoption and defence of the general doctrine of the universality of symptomatic fever, Broussais contends that the in- flammation or irritation whence the febrile sympathies radiate as from a focus, is almost universally located in the mucous membrane of the alimentary canal; and hence gastro-enteritis is with him the fons et origo of febrile phenomena. That fever is a very common result of local inflammation, is un- questionable. So intimate are the sympathetic relations between all the various parts of the animal body, that no structure or organ can be strongly irritated without causing a sympathetic irritation in other organs or structures. If the primary irritation involve the sanguiferous capillaries, the irritation will be communicated by sym- pathy to the general vascular system, and fever will be the result; but if the local irritation be purely nervous, it will be diffused, and as it were locked up in the general nervous system, and give rise to convulsions, or some other form of general nervous affection. With- out doubt too, inflammation of the mucous membrane of the aliment- ary canal is much more common in febrile diseases than was for- merly, and by many is still supposed. It is even probable that in many instances of fever, such an inflammation constitutes the pri- mary and essential cause of the febrile phenomena. This is, perhaps, most apt to be the case in those instances of fever which result from the combined agencies of impure and indigestible diet and atmos- pheric vicissitudes. But although we may admit the correctness of these observations, yet to refer all fevers, remitting, intermitting, ' and continued, to gastro-enteritis, is as remote from truth as it is detrimental in its influence on practice. The advocates of the physiological doctrine, as it is called, endea- vour to support their sentiments in relation to this subject, by the phenomena detected on post-mortem examination, and by arguments founded on physiological principles. It is affirmed that marks of inflammation almost universally occur in the mucous membrane of the alimentary canal, in subjects that die of febrile affections. The capillary vessels, to a greater or less extent, of this membrane, it is said, are found injected; and in many instances other and less equi- vocal traces of previous inflammation are discovered. Admitting that such manifestations of inflammation are as universal as they are asserted to be, is there not much reason to believe that, very frequently at least, the inflammation supervened during the course of the disease, as a consequence of the fever, rather than that the inflammation was pre-established, and became the immediate exciting cause of the fe- brile phenomena? We frequently see inflammations supervene in parts exposed to observation many days after general fever has been fully established. Indeed, when it is considered that in all febrile GENERAL PATHOLOGY OF FEVER. 17 afiections, the secretions which are poured into the intestinal tube, are unnatural and vitiated—that the process of digestion is suspend- ed, or much impaired, and consequently, that fermentation and de- composition of the contents of the stomach and bowels are especially favoured—is there any cause to wonder that we should so often meet with traces of inflammation in the digestive organs in those who die of febrile affections? The Broussaian mode of treating fevers, although especially meant to obviate such inflammations, appears to me, in one respect, well calculated to favour their occurrence. The almost total proscription of purgatives from the list of our remediate means for the treatment of fever, so far from lessening the tendency to gastro-enteritis, tends, I conceive, in general, to an opposite result. In a recent work by Bouillaud, there are upwards of sixty cases of fever reported, in not a single instance of which was there a purga- tive medicine administered by the mouth. In all of these cases, however, marks of inflammation, and in the majority ulcerations were detected in some portion of the mucous membrane of the bowels. That this should have been observed, will not appear strange, when it is considered that in all the cases, most of which continued from three to four weeks, all the acrid and vitiated contents of the intes- tines were suffered to remain, undisturbed, to act on their delicate lining membrane. To one not thoroughly imbued with Broussaism, it does appear strange that any one should withhold a laxative, under the appre- hension of its causing injurious irritation, and yet suffer, without any such fears, the most irritating substances to lie quietly in the bowels. It is true, laxative lavements were repeatedly resorted to in these cases, but that these did not disturb or remove the acrid materials which were enclosed in the bowels, is abundantly manifest from what Mr. Bouillaud himself has stated. After having gravely told us that in all the cases he describes, the traces of mucous inflamma- tion in the bowels were trhs prononce", he states that, " in general the stomach and small intestines were filled with a yellowish or greenish bile, and that the residue of the alimentary substances which were found in the small and large intestines, invariably exhaled an intolerably fetid smell, and frequently exhibited the consistence of mustard. This residue, mixed ivith various fluids secreted in the intestines, appeared to have undergone a complete process of putrefactive decomposition, as was evident from the extreme offensiveness of the smell, and the fetid gas which dis- tended the bowels."* Can it be reasonably supposed that the transient and moderate irritation of a purgative in these cases would have been more inju- rious than the constant impressions of the acrid and irritating sub- stances which were so long left in immediate contact with the bow- els? It is thus, it can hardly be doubted, that many instances of * Traite Clinique et Experimental de8 Ficvres. Par J. Bouillaud, Paris, 1826. Vol. I.—3 18 GENERAL PATHOLOGY OF FEVER. .. gastro-enteritis, so abundant in the practice and dissections of t vBroussaian school, are developed. Were laxatives employed wiui due .moderation, it is probable, that the so much dreaded gastro- e'nterite would in some instances, at least, perhaps in many, oe •' prevented, and the world deprived of a large proportion of those tri- umphant demonstrations which are continually brought out in lormi- dable array in support of the phisiological doctrine. As a further offset to the evidence adduced from post mortem ex- amination, it must be observed, that so far as the mere redness or injected state of the mucous membrane is concerned, we can draw no certain inference as to the previous existence of inflammation in this structure. That these phenomena are frequently the result of changes affected in articulo mortis, or post mortem, is fully de- monstrated by the observations of Mr. Yellowly and of Mr. Seeds.* * " It must have happened to every one," says the former of these writers, " accustomed to the examination of dead bodies, to see appearances of vascular injection in the villous coat of the stomach. Such appearances have very fre- quently been referred to inflammation, but they have probably been but little studied. I have several times been present at the examination of bodies, where the vascularity of the villous coat of the stomach was so considerable as even to give rise to suspicions that' the appearance had been produced by something de- leterious. 1 was therefore induced to embrace frequent opportunities of viewing the state of the inner surface of the stomach, and I so often found in it the ap- pearances alluded to, as to induce me to imagine, that the opinion which is commonly entertained of their being marks of disease, is not well founded. In persons suddenly destroyed, when apparently in perfect health, he found the mucous membrane of the stomach highly injected." Mr. Seeds too, found that in animals bled to death, the membraneous structures frequently exhibit a state of injection which might, at first sight, be readily mistaken for inflammation. It is well known that the arterial tubes possess a power of contracting to a considerable extent, by what Bichat calls the contractility of texture, and that this power is not limited to the period of life, but continues some time after death. It is equally ascertained that the capillaries are endowed during life with a peculiar degree of sensibility which causes them to resist the entrance of such fluids as they are not destined to convey in the performance of their natural functions. This peculiar sensibility, by virtue of which, the serous capillaries refuse, or contract against the intromission of red blood, would seem to depend on the regular influx of the nervous influence. That this is the case, appears highly probable, if not certain, from the different results arising from the forci- ble injection of fluids into the arteries in living and dead animals. " Push into the aorta of a living animal, by means of a syringe, different fine fluids, and you will never see them fill the capillary system, or issue by the exhalents*" when however, the same experiment is performed on an animal soon after death the fluid will be found to pass readily into the serous capillaries, and pass out bv the exhalents, excretory ducts, &c. {Bichat.) Mr. Buniva's experiments, quoted by Bichat, with injections upon dead and living animals, illustrate this fact in a very striking manner. He fixed the pipe of a syringe into an artery of a living GENERAL PATHOLOGY OF FEVER. 19 Broussais and his followers are, indeed, fully sensible of the obser- vation of Celsus: Neque quicquam esse stultius quam quale quid vivo homine est, tale existimare esse moriente imo jam mortuo; for where they fail in detecting a red and injected state of the mu- cous membrane of the bowels, they account for its absence by ascribing it to a post mortem, change; thus availing themselves of this fact when it affords an argument in their favour; whilst they manifest an unwillingness to allow any importance to it when it is adduced against their doctrine. It cannot, indeed, be presumed that the injected state of the mu- cous membrane of the intestinal tube, so often discovered in those who die from fevers, is always, or even generally, to be ascribed to a mere post mortem change; but that such changes do sometimes, nay, often occur, and that they have been assumed as evidences of previous inflammation, there can exist but little doubt. The first obvious effect of the remote febrific causes, consists almost universally in a diminution of the nervous energy, and con- sequently of the action of the heart and arteries. This is manifested by the weak and contracted pulse, the general languor and lassitude, the diminished temperature and the sense of chilliness which usher in all febrile affections. These initial phenomena of fever are espe- cially conspicuous in intermittents, remittors, and in catarrhal affec- tions. There is nothing in the character o^these symptoms which can justify the inference that they are dependent on inflammation. " Inflammation," says Dr. Armstrong, " cannot exist in the cold stage of fevers, all the phenomena of which are directly opppsed to inflammation." The course and phenomena of intermitting fevers present us indeed with insurmountable objections to the "phisiolo- animal; on endeavouring to force the fluid into the vessel he found very great resistance, the piston passing down very slowly, and only with the application of much force. On causing the animal to be suddenly killed, by dividing the spinal marrow just below the occiput, the fluid passed* rapidly out of the syringe into the artery, although but little force was applied. While the capillaries retained their full portion of vitality, they resisted the introduction of the fluid; but as soon as they had lost their sensibility, in the death of the animal, they yielded like passive tubes to the fluid forced upon them by the vis a tergo. The application of these facts to the post mortem production of a red and injected state of the membraneous structures, especially the more vascular ones, is easily to be understood. So long as the serous capillaries retain their vitality, they resist the entrance of red blood into them. As soon, however, as their vital pro- perties cease to exist, they lose the power of resisting the intromission of red blood—becoming, in fact, mere passive and yielding tubes. But as the arteries continue to contract on their contents, some hours after the extinction of life, they must necessarily force the blood forward into the relaxed and unresisting capillary system, into which it will therefore be driven, as inl^ a sponge, and give to the more vascular structures, the red and injected state, so often found on post mortem examination, where no previous inflammation whatever existed. 20 GENERAL PATHOLOGY OF FEVER. gical doctrine." The periodicity of these fevers is strongly op- posed to the idea of their immediate dependence on the gastro- enteritis. It is, indeed, true, that affections of an inflammatory character, have been known to recur in a strictly periodical manner; but such cases must be viewed as anomalies, and altogether contrary to the almost universal course and character of phlegmasial diseases. An inflammation which observes a perfect periodicity in its attacks, must be sui generis. If intermitting fever depend on inflammation of the mucous membrane of the alimentary canal, then must this inflammation be periodical, and therefore essentially distinct from the inflammation which produces remitting fever; for in this mal- ady it must be continuous. These two forms of fever are, however, produced by the same remote cause; and we are therefore forced to admit, by the assumption of this doctrine, that the same remote cause is capable of producing two kinds of inflammation essentially distinct from each other. The character of the remedies, too, which have been found most effectual in arresting intermitting fever, is directly opposed to the idea that gastro-enteritis constitutes its proximate cause. Who can believe that quinine, arsenic, black pepper, and other remedies of a similar character are peculiarly calculated to cure inflammation of the mucous membrane of the alimentary canal? Indeed, these very artickg^ appear to be particularly dreaded by the disciples of this doctrineJ*m account of their tendency to create gas- troenteric irritation, and yet all experience goes to prove that they are decidedly the most prompt and valuable means for the cure of intermitting fever. M. Broussais' theory of the mode in which the remote causes of febrile affections produce gastro-enteritis is gratuitous, and but little calculated to satisfy the understanding. "Every irritation," he says, " which is capable of producing a perception in the brain, passes back by the nerves to be repeated in the mucous mem- branes." Thus, if a person be inoculated with small-pox virus, the irritation of the primary pustule, or of the inoculated point, is con-' veyed to the brain, whence it is reflected by the nerves upon the mucous membranes of the alimentary canal, where it establishes an inflammation. This intestinal inflammation constitutes the essential cause of eruptive fever, and the eruption itself is only a metatastic disorder of the cutaneous system. The assumption then, " that every irritation which is capable of producing a perception in the brain is reflected by this organ to be repeated in the mucous membranes of the alimentary canal, forms the main principle in the Broussaian doctrine of the etiology of fever. That the mucous membranes of the intestinal tube possess a very wide sphere of sympathetic rela- tions, is a fact indeed as undeniable as it is important in a patholo- gical point of view. But that this structure constitutes a subordinate sensorium commune, to which all morbific impressions are especially eonveyed, after having been perceived by the brain, is a position which all the zeal and ingenuity of its advocates have as yet failed GENERAL PATHOLOGY OF FEVER. 21 and I apprehend will ever fail to place upon that firm basis, which it ought to have to serve as a foundation of our pathological faith. I do not mean to object to the general fact, that all impressions capable of ultimately exciting fever, are in the first place communi- cated to the sensorium commune, and thence reflected throughout the system, and sometimes upon some particular organ or structure; but this reflected impression does not, it may be justly maintained, necessarily establish a focus of irritation, nor always, or even gene- rally, fall especially upon the intestinal mucous membrane. If the impressions of morbific causes are always transferred to the mucous membrane of the alimentary canal, the impressions of all agents, remedial as well as others, must of course be referred to the same structure. This, however, does not accord with the results of observation. When mercury is rubbed on the skin, the salivary glands, the gums, and the mucous membrane of the mouth, receive the chief impressions excited by this agent. Will it be contended that a gastro-enteritis must be established before salivation can be produced? If opium be applied to any part of the body, the impress- ions are concentrated in the nervous centre. When cantharides are applied to the surface, the irritation is conveyed to the neck of the bladder, and not to the mucous membrane of the bowels, and yet fever may be the result. From these and many other similar facts that might be adduced, it is manifest that%ie supposed 'law of the animal economy, by which, as is alleged, all febrific impressions are reflected from the brain and repeated in the mucous membranes of the bowels, is gratuitous, or to say the least, highly improbable. The fallacy of those doctrines which confine the primary inflam- mation to some one structure exclusively, is strikingly illustrated by the circumstance, that different writers have fixed on different structures, as the parts primarily affected in fevers. Thus Clutter- buck maintains, with Broussais, that fever is always a purely symp- tomatic affection depending on local inflammation pre-established by the febrific cause. He asserts that this primary inflammation is inva- riably located in the brain and its membranes, and adduces the phe- nomena discovered on post mortem examination, in testimony of the correctness of his doctrine. Broussais, on the other hand, asserts that the primary inflammation is not in the brain, but in the mucous membrane of the bowels, and appeals with equal confidence to the appearances exhibited on dissection for confirmation of his doctrine. This discrepancy is in itself sufficient to show the weak founda- tion on which these two doctrines^est; for if the evidence afforded by autopsic inspection in relation to this subject were not extremely ambiguous, it would, one may suppose, be impossible to draw from it conclusions so very discrepant, and yet so nearly equal in point of plausibility. The advocates of the gastro-enteritic pathology of fever, place no inconsiderable reliance for support to their doctrine on, what they are pleased to assert, their superior success in the remediate manage- 22 GENERAL PATHOLOGY OF FEVER. ment of fevers. Leeches, and an almost total abstinence from food, with cooling, acidulated, mucilaginous drinks, constitute nearly the whole of their remediate applications; and they claim for this mode of treatment, a greater success than that which they allow to others who pursue a more active course of treatment in fevers. It does not appear, however, that the golden age of medical success, so confi- dently promised by Broussais, on the introduction of his doctrine, has as yet arrived;* for the statements which have been published in France, in reference to the comparative mortality under the Broussaian, and the other modes of treatment, give no support to the claims of superior success set up for the former. We might, how- ever, admit the excellence of the Broussaian mode of treating fevers, without yielding our assent to the correctness of the doctrine that the gastro-enteritis is primary where it does exist. There exists but little doubt in my mind, that in continued and remitting fevers, active purgation is not unfrequently carried to an injurious extent; for although we may, and, as I conceive, ought, to reject the opinion that such fevers depend essentially on the gastro-enteritis, yet we cannot doubt, that a very considerable degree of irritation, amount- ing in many instances to inflammation, does often supervene during the progress of the disease, as an epiphenomenon, and unconnected with the origination of the fever. In cases where such a condition of the mucous membrancof the intestinal canal occurs, during the course of the disease, the soothing treatment recommended by Brous- sais, is no doubt more salutary than the vigorous purgative plan so commonly pursued in this country and in England. Unquestiona- bly, intestinal irritation and inflammation perform an important part in febrile diseases. These conditions may arise as consequences of the general febrile reaction, as well as from harsh and repeated pur- gation, and the use of other irritating remediate agents. But it is equally probable that gastro-enteritis is often excited by acrid and vitiated secretions, and other offensive materials retained in the bowels in consequence of withholding suitable laxatives, in the com- mencement and during the progress of the malady. Broussais has done much good, by awakening the attention of the profession to these pathological conditions; and thus furnishes another proof of the fact, that new doctrines, though fundamentally erroneous, seldom fail to do some good, by directing the views of physicians to import- * In 1821, Broussais asserted " that the tables of mortality declare in favour of the new doctrine, and that its influence upon population would be more favoura- ble than that of the introduction of vaccination.'''' Unfortunately, however this happy influence of the nouvelle doctrine, remains yet to be realized;* and the ad- vocates of the doctrine may console themselves for the tardiness of this influence with the certain prospect of not being very soon deprived of the opportunity of publishing their ordinary quantum at post mortem examinations. * Refutation iuiiy confirmed by experience. . - , Inequilibrium of the circulation and excitement, is one 01 tne most important characteristics of fever. Although fever is emphati- cally a general malady, and a morbidly excited condition, it must not be supposed, that every sensible and irritable structure, though functionally deranged, is in a state of increased excitement. While the heart and arteries are energetic, and morbidly active, the muscu- lar system is usually languid, and enfeebled. An increased activity of the intestinal capillaries and exhalents, may be attended with diminished activity of the capillaries and exhalents of the external surface. Inordinate action of the kidneys is often accompanied with torpor of the liver, and always with torpor of the cutaneous exha- lents. Sometimes the capillary system is inordinately active, whilst the heart and arteries manifest but little or no increase of excite- ment; and occasionally the brain and nerves are in a state of great activity, with very feeble reaction of the heart and arteries. The same observations apply to the distribution of the blood. Whilst it is morbidly deficient in some organs, it will be excessively abun- dant in others; whilst the capillaries of one structure or organ are engorged and inflamed, those of other parts will be devoid of the regular portion of the circulating fluid. These facts have a most important bearing on practice; for they point directly to the funda- mental principle of treatment,—namely, to excite and invigorate those organs that are torpid, at the same time that we depress and debilitate those that are morbidly active. It has been supposed that febrile excitement, or the essential mor- bid action of fever, is always the same; and that the various modifi- cations which this form of disease is .known to assume, depend wholly upon the local irritation or inflammation which may occur, or rather the organ or structure which may be its seat. To a cer- tain extent, this opinion appears to be well founded. It is very evi- dent, for instance, that in proportion as the brain and nerves become affected, so will the fever acquire a low or typhoid grade in its gene- ral character. Of two individuals seized with fever from the influ- ence of atmospheric vicissitude, one will, perhaps, be affected with a low or typhoid form of fever, whilst in the other, the fever will assume a high grade of inflammatory or synochal reaction. In the former, prominent symptoms of severe nervous disorder will attend; and if the disease be violent, decided manifestations of cerebral in- flammation will probably occur. In the latter case, little or no pro- minent signs of cerebral disturbance or irritation will ensue- but in- stead of this, symptoms of local inflammation in the fibrous or serous structures, or in one or more of the abdominal organs, will probably be observed. That the occurrence of irritation or inflammation of the brain GENERAL PATHOLOGY OF FEVER. 37 should impart a low and typhoid character to fever, and thus give to it a peculiar aspect, is by no means difficult to comprehend; for, it is manifest, that when the fountain of the vital energies, the brain, is prominently deranged, all the powers of life, however ex- cited, must languish and sink. This subject will, however, be more particularly discussed under the head of continued fever, being re- ferred to at present, merely for the purpose of directing the reader's attention to the general fact, that fevers, arising from the same cause, and essentially identical, receive important modifications from the seat and grade of the local affections which may supervene. The mode in which the occurrence of local inflammation may be favoured during the progress of fever, has already been mentioned. Besides the peculiar influence of the remote causes, in deranging particular organs or structures, in preference to others, and thus lay- ing the foundation for local inflammation, there are, however, other circumstances which are, perhaps, still more commonly concerned, in favouring the supervention of inflammation, and inviting it to particular organs. The human system is rarely found in so perfect a state of health, as that some of its various organs or structures are not more or less debilitated or disturbed. The multifarious influ- ences that are continually operating on the animal economy, do not suffer the vital machine to go on without some, though often imper- ceptible, derangement in one or more of its various organs. Add to this, the congenital debility of some structures, and the constitu- tional prepotency of others, and we have a sufficient number of latent causes, (varying in different individuals, and in relation to some, in the same individuals at different periods,) to determine the occur- rence of local inflammation, when the nervous and vascular systems are thrown into a state of tumultuous excitement. Much variation occurs in different cases, as to the period after the commencement of the febrile changes, when local inflammations of this kind supervene. If any organ or structure happen to be espe- cially predisposed to inflammatory excitement, or when the exciting cause is of such a nature as to act with great force upon some organ or structure, inflammation may commence with the onset of the febrile vascular reaction. More commonly, however, the local in- flammation does not supervene until several days after the com- mencement of the fever; and in many instances, not until the latter period of the disease. The occurrence of local inflammation in general fevers, of course, always greatly increases the obstinacy and danger of the disease; and this is pre-eminently the case, when such inflammations supervene in fevers of typhoid character. Prone as febrile affections unquestionably are, to give rise to secondary inflammations, many instances occur which remain en- tirely free from inflammation throughout the whole course of the malady, although irregular determinations and inequilibrium of ex- citement appear to be inseparably connected with this form of gene- ral disease. 38 GENERAL PATHOLOGY OF FEVER. It has been observed above, that fevers, essentially identical in the nature of the general febrile excitement, often assume prominent modifications, apparently radically diverse from each other, in con- sequence, solely, of the different organs or structures which happen to sustain the principal force of the malady. From this unquestion- able fact, some pathologists have inferred that there can be no fun- damental and specific diversities of fever, presuming that the general febrile excitement is always essentially the same; and that all the diversities which occur in the course and phenomena of this mode of disease, are invariably the result of the diverse local affections that may accompany the malady. It appears to me, however, that the occurrence of original and specific diversities in the nature of febrile excitement, is susceptible of very plausible, and, to me at least, sufficiently satisfactory illustration. It is impossible to con- ceive why the capillary system of blood-vessels, in which doubtless all the essential febrile actions reside, should not be as susceptible of radical diversities of excitement as the nervous system itself. Upon this point we may be allowed to refer to the exanthematous affections; for, whatever Broussais and his followers may say to the contrary, some of these diseases are, at least in the first stage, simply febrile, without local inflammation. In the general phenomena of the fever of distinct small-pox, during the first day of its course, there is nothing that is different from an ordinary synochus; and yet no one can for a moment seriously doubt, that the essential morbid excitement of the extreme vessels in this affection, is specifically distinct from that of all other febrile diseases. It is true that this disease is produced by a specific cause; but the morbific impressions made by malaria, are probably as distinct from those of cold, as the impressions of small-pox virus are from those of either of them. No one has ever observed yellow fever or the plague to arise from atmospheric vicissitudes; and malaria by itself, has, I presume, never been known to give rise to inflammatory rheumatism, or to simple catarrhal fever. If, then, in relation to the exanthemata, general febrile excitement is unquestionably susceptible of radical and specific peculiarities, the possibility of such fundamental diver- sities in the nature of the morbid excitement of fever, independent of accidental local affections, must be admitted, even in the general fevers, usually denominated idiopathic. It is probable, that koino- miasmata, idio-miasmata, and cold, or atmospheric vicissitudes, produce each its peculiar mode of morbid excitement; for, although the general and obvious febrile actions, and even the accompanying local affections which they respectively produce, may not be per- ceptibly diverse, yet, it may be presumed, the fundamental morbid condition or excitement of the nervous and capillary systems upon which the febrile phenomena depend, is in each variety of fever radically distinct, or sui generis. So far, however, as the fevers occasioned by one or the other of these remote causes, differ in form and general character from each other—as, for instance, the various CAUSES OF FEVER. 39 forms of miasmal fevere—it can scarcely be doubted, that the most common source of these diversities consists in the accidental local affections which occur, or the character of the structure most promi- nently deranged, or the greater or less intensity of the operation of the remote cause. CHAPTER II. OF THE CAUSES OF FEVER. The causes of fever are generally divided by pathologists into two varieties, the predisposing and the exciting. The former are all those external and internal causes, which tend to lessen the power of vital resistance to the influence of morbific agents. The latter are those causes which excite actual disease by the deleterious or irri- tating impressions which they make on the animal system. There exists, however, no absolute difference in the nature or character of these two varieties of morbific causes. The-same agent, or circum- stance, may manifest its influence on the animal economy, either as a predisposing or an exciting cause of fever, according to the de- gree of intensity with which it acts, or the previous condition of the system. Sect. I. Of Predisposition, and Predisposing Causes. When, either from a general condition of the organization, or some local functional or organic defect, the animal economy is especially susceptible of the influence of morbific causes, a predisposition to disease is said to exist; and this predisposing condition may be either natural, or accidental, or hereditary. As the human system is continually under the influence of causes which have a tendency to interrupt and terminate its actions, life would be but ephemeral in its duration, and harassed by constant disease, if the animal organization were not endowed with the inhe- rent power of resisting, to a degree, the influence of injurious causes. It is by the aid of this vital resistance, that man is enabled to live through a long series of years, amidst a multiplicity of causes, which conspire unceasingly to his destruction. In relation to the degree, in which this power of resisting injurious influences is possessed, by different individuals, there exists great diversity; and hence the va- rious degrees of constitutional or natural predisposition to fever, which obtains among different individuals. Thus, the prick of a needle will, in one individual, cause great pain and constitutional irritation; in another, syncope; in a third, convulsions or tetanus; 40 CAUSES OF FEVER. and in a fifth, scarcely any perceptible consequences at all.* There exists, therefore, a natural or constitutional predisposition to dis- ease in some individuals, wholly independent of accidental causes, or mere casual debility; and this constitutional aptitude to disease, depends, probably, on the peculiar organization of the animal system. Under the head of natural, or constitutional predispositions, must be ranked those specific predispositions, which render the system susceptible of certain specific diseases, and which are wholly lost by the actual occurrence of these maladies. These specific predisposi- tions are especially incomprehensible and mysterious. Neither tem- perament, nor constitutional vigour, nor debility, nor any circum- stance connected with the health of the individual, appears to have any relation with, or influence upon them. With regard to accidental, or acquired predisposition, observa- tion has not left us so entirely in the dark. According to the late Dr. Rush, general or local debility, accompanied by an increased ex- citability, constitutes the state of predisposition to fever. Without doubt, general debility, with increased excitability, must render the system more liable to the acrion of irritating or exciting causes; yet it does not appear, that this condition of the system can, with pro- priety, be considered as constituting the essential state of the organi- zation which predisposes to fever. It is well known, that the most robust and healthy individuals, are generally the first and most cer- tain victims of febrile epidemics. The vigorous and healthy are often prostrated under the devastating dominion of pestilence, and even under the less ruthless sway of the milder paludal fevers, whilst the feeble and the valetudinarian pass along untouched. It may, moreover, be observed, that in the feebleness of convalescence from bilious, typhus, and other forms of fever, fresh attacks, or relapses, are by no means so common as one would expect, if mere debility constituted febrile predisposition. When we wish to obviate fever, after a surgical operation, we reduce the system by low diet, purga- tion, and perhaps blood-letting.t In a general way, every cause, capable of deranging the health of the animal economy, may, when acting with moderate force, produce such a change in one or more organs, as will predispose the system to fever, requiring only some further exciting cause to evolve actual febrile disease. Predisposition, produced by the influence of acci- dental causes, consists, probably, always in more or less functional derangement of one, or at most, a few structures or organs, or in a disturbance of the healthy balance of excitemeut and the circulation. I have already stated some reasons which render it highly probable, that the impressions of every morbific cause, on whatever part of the system primarily made, is, in the first place, reflected upon some * Sur le differens Degrees de Resistance vitale dans les Maladies &c. Par M. L. Martinet, M. D.—Revue Medicale, Octfr. 1824. | Richter's Specielle Therapie. vol. I. p. 36. CAUSES OF FEVER. 41 particular organ, according to the nature of the impression, and the organic sensibility of the various parts of the system. If this be cor- rect, it is manifest, that if the morbific impression, thus reflected upon an organ or structure, be too weak to establish a sufficient de- gree of irritation to excite general derangement, or febrile reaction, the result will be only a slight degree of insulated functional de- rangement, or irritation, which, though not manifested by any feel- ings or appearances of ill health, is still an incipient link of disease, and wants only some additional morbific influences to enable it to put in motion the latent train of morbid sympathies. How greatly mere functional derangement of an important organ aids the cause of fever in developing disease, is often conspicuously illustrated by the influence of digestive derangement in the production of fever. Let but this citadel of the animal system languish, and the enemies of human health will speedily attack the outposts, and make an easy conquest of the whole. Hence, of all the precautions which those who visit insalubrious climates may be required to adopt, the avoid- ance of every thing which is calculated to derange the digestive func- tions, is perhaps the most important.1 B37 a well-known law of the animal economy, every agent, how- ever deleterious, gradually diminishes, and finally almost destroys the susceptibility of the system to its influence, by long continued or very repeated action. Hence, every agent will, cseteris paribus, manifest its operation with a promptitude and intensity, proportion- ate to the degree of previous immunity from its influence. It is this circumstance which causes the difference of predisposition to endemial fevers, between the acclimated natives of insalubrious regions, and strangers arriving from northern latitudes. This variety of predisposition depends in no degree on a want of constitutional vigour or general health. The robust and healthy are, in general, as much, if not more, under its influence, as the weak and infirm. By a gradual or protracted exposure to morbific agents, the animal economy loses, insensibly, its natural susceptibility to their influence. When such a change is effected by the combined operation of cli- mate and endemial morbific agents, the system is said to be accli- mated or seasoned, and the individual, thus seasoned, enjoys a com- parative immunity from the diseases of the climate. Besides the foregoing source of predisposition to disease, from causes peculiar to hot climates, there is another and perhaps not less powerful one—namely, atmospheric heat. High atmospheric tem- perature is, strictly speaking, rather a predisposing than a morbific agent in relation to its influence on the human system.* In this respect it exercises a very powerful influence in the production of diseases. Long continued exposure to an elevated degree of solar heat, tends, very considerably, to increase the general irritability of the system, and to lessen the power of vital resistance. Hence, the * Dr. James Johnson on Tropical Climates, &e. Vol. I.—6 42 CAUSES OE FEVER. frequency of tetanus in hot climates, from injuries, or from the influence of the cool and damp night air; and hence, too, the greater liability to this and other irritative affections, during the hot seasons of our own climate, than in the cold months. Atmospheric heat tends, moreover, to predispose to fever, and other affections, by the profuse and continued perspiration it causes, as well as the redund- ant secretion of bile it is apt to excite. By these over-excited actions of two important organs, the general system is exhausted, whilst the organs themselves'are rendered more susceptible to the injurious impressions of one of the most common and powerful ex- citing causes of disease—namely, cold. In relation to those predispositions to disease which are transmit- ted from parent to offspring, it may be sufficient to observe, in this place, that they depend, no doubt, on a peculiar physical condition or intimate state of the organization, which we may presume, is as apt to be imparted by the parent to the offspring, as the contour of the countenance, or of the general structure of the body. Sect. II. Of the sources of Morbific Causes, and their General Character. When we take a general survey of the source of all the possible causes of disease, we find that, in relation to their origin, they range themselves under the following four general heads, viz.* I. Recrementitious substances, which, in health, are separated and thrown out of the system, but being retained in the cir- culation, or reabsorbed, become a source of irritation to the sanguiferous system, and, therefore, of iritative diseases. These morbific causes are always secondary, being, them- selves, the consequences of an anterior injurious cause or im- pression. Thus the retention of the perspirable matter, can occur only in consequence of the influence of some previous cause, adequate to disturb or arrest the action of the cutane- ous exhalents. The recrementitious fluids, which appear to be most injurious to the animal economy, when retained in the circulation, even in their elementary forms, are the per- spirable matter, the bile, and the urine; and of these the first is, perhaps, the most frequently concerned in the production of disease. The influence of causes of this kind in the de- velopment of disease, is, probably, much more extensive than is generally admitted in etiological inquiries. In all that ex- tensive class of febrile affections which arise from the influ- ence of cold, retained perspirable matter performs, probably, a principal part in the development of the irritative vascular excitement. Checked perspiration, or, more correctly speaking, inactivity of * Richter's Specielle Therapie, vol. I. CAUSES OF FEVER. 43 the cutaneous exhalents, constitutes the initial link in perhaps, three- fourths of our febrile diseases. Let it not be imagined, that, as the recrementitious substances which are retained in the circulation are in a simple or elementary state, they cannot possess powers suffi- ciently irritating or active to excite morbid vascular action. In whatever form these substances may exist in the blood, they are still recrementitious, and it is not to be presumed, that materials of this character, could be long retained without an injurious influence on the animal economy. Accidental torpor of one emunctory, is often vicariously supplied, by increased activity of another, and disease thus prevented. Thus if, after the cutaneous exhalents have been rendered torpid by the sudden influence of cold, the flow of urine becomes unusually copious, disease will rarely ensue. Indeed, the all-wise and benevolent Creator, has provided against the inju- rious consequences, which must otherwise have resulted from the constant changes to which the function of the skin is necessarily ex- posed by placing in the interior, an organ, whose functions may, in a great degree, supply any accidental deficiency in the action of the former. II. Irritating substances, generated within the body, but wholly independent of any organic actions. These causes of di- sease are usually generated in the primae viae, and consist of worms, acids, mucous, and various other irritating substan- ces, resulting from the fermentative or putrefactive pro- cesses. Worms have been, and by some are still considered as innocent inmates of the human body. This, however, is most certainly an erroneous sentiment. Without doubt, a few, or even a considerable number of worms lodged in the alimentary canal, may not be able to disturb the general system, when in a state of good health and constitutional vigour; but when the body is debilitated and irritable, as it commonly is during the period of dentition, the presence of worms in the intestinal tube will frequently give rise to the most alarming affections. Worms tend, moreover, to sustain and protract fevers produced by other exciting causes; an inattention to which, frequently renders the progress of ordinary diseases peculiarly per- plexing and unmanageable. It is not uncommon to meet with cases of slight febrile disease in children, from cold, which continue in spite of appropriate remediate efforts, gradually assuming the form of slow remitting fever, with a foul tongue, and gastric disturbances, and at last, suddenly assume a favourble aspect, on the expulsion of a few large lumbrici. The agency of causes of this kind in the production of fever, was, however, formerly considered much more extensive than it appears, in reality, to be. Verminous epidemic fevers are described by some of the older writers, and saburral fevers were supposed, as it would appear, very common. Without ascribing so great an importance to these causes, as originators of fever, it is, nevertheless, unques- 44 CAUSES OF FEVER. tionable that they do, at times, give rise to febrile affections, inde pendent of all other morbific irritants. Their febrific tendency is, however, much more frequenly manifested in the support, or aaai- tional violence which they give to fevers arising from other causes, than in originating febrile affections by their own immediate influ- ence. III. Morbific agents, generated out of the animal body, con- sisting, either of deleterious substances floating in the air, or of the sensible properties of the atmosphere, or, finally, mechanical causes—namely; miasmata, noxious gases, heat, cold, electricity, humidity, and mechanical injuries, &c. IV. The fourth and last class of morbific agents comprehends those which are generated by morbid organic actions of the living system, constituting the various contagions. The principal causes, embraced under the two last heads, are so extensive in their influence on the human system, and so interesting and important, both in a medical and scientific point of view, that a separate and full exposition of their respective modes of origin, and physical, as well as morbific characters, will not be deemed inappro- priate in a work of this kind. Section. III. Atmospheric Temperature, and its relations with the Animal System. A certain quantity of heat is indespensable to life, throughout the whole range of organized beings. Every animated being possesses an inherent power to generate heat, and to resist, to a certain extent, the physical law of the distribution of heat; and, consequently, to maintain its peculiar or specific temperature, when placed in a me- dium either many degress below or above its own temperature. The constant and rapid reproduction of heat by the vital powers, keeps up the natural temperature of the animal body, although surrounded by a medium which abstracts its heat, with great rapidity. Such, indeed, is the evolution of heat by the human body, that an atmo- sphere of the temperature of 98° is generally oppressive and unplea- sant by the feeling of warmth which it causes, although at this tem- perature of the air, no heat can be communicated by the surrounding atmosphere to the body. The temperature most grateful and invi- gorating to the human system, ranges from about 60° to 65°. "This temperature of the air appears ).o abstract the heat of the body in about the same proportion in which it is generated in the healthy state of the system; and this degree of the temperature is, therefore, the most congenial, for it neither exhausts the vital powers nor greater specific gravity than atmo- spheric air, (De Lisle.) They cannot, consequently ascend into the air without being attached to and carried up by lighter bodies; and these vehicles consist, without doubt, of aqueous vapours. Hence, persons sleeping in elevated chambers, are much less apt to contract miasmal diseases than such as are lodged on the ground floor, (Hun- ter on the diseases of Jamaica, Blane, Lempriere,* De Lisle.) And hence, too, the greater salubrity of hills, and very elevated parts, than the adjoining low grounds. The ancient Romans appear to have been fully aware of this fact, and they availed themselves of it by almost uniformly selecting very elevated positions, or hills, for the sites of their towns. It is true, that some very remarkable ex- ceptions have occurred to this fact. Bancroft mentions the great mortality which has repeatedly been observed on the top of Monte- fortune, at St. Lucie; and on the Hospital and Richmond hills, at Grenada, while the surrounding low situations were comparatively salubrious. Dr. O'Hallaran, in his account of the yellow fever of the south and east coasts of Spain, mentions similar examples of the great prevalence of miasmal diseases on verj elevated situations, * Drs. Blane and Lempriere, in their report to the Secretary of War, con- cerning the Walcheren fever, observe: « On no account should ground floors be used to sleep on: the more lofty the buildings the better, for the tenants of the upper stories not only enjoy the best health, but, when taken ill, have the disease in the mildest form."—Bancroft on Marsh Exhalations. MIASMATA. 55 whilst the surrounding marshy grounds were but little infested with this deleterious effluvium. He refers particularly to Monjui, a hill 700 feet high, overlooking Barcelona, the air of which, he says, is so deleterious, that it was found necessary to relieve the stationary guard every eight or ten days; and, he adds, that the injurious influ- "ence of the exhalations arising from the swamps below, manifested itself more conspicuously upon the summit of the hill than in the subjacent parts. Dr. Blane, who mentions similar facts, explains them by supposing that the vapours formed on the low and swampy grounds ascend, and, with the miasmata which they hold in solution, pass over the lower situations and impinge and settle on the neigh- bouring hills. It is, indeed, by no means uncommon to see fogs, which rise out of the low grounds, ascend and hover over the tops of the neighbouring mountains, and it may well be presumed, that these fogs will convey along with them a large portion of the mias- mata which may be extricated from the same grounds whence the aqueous vapours arise. Koino-miasmata is abundantly precipitated to the surface of the earth during the night, and more especially during the first hours after the setting, and shortly before the rising of the sun. Hence, in part, the greater liability of contracting miasmatic diseases from exposure between the setting and the rising of the sun, than after the sun is considerably above the horizon, (De Lisle, Bancroft, Sir James Fellows, Johnson.) The most dangerous period in the twenty-four hours of the day, is " that which accompanies the set- ting and that which immediately precedes the rising of the sun, and the least critical time is when the sun is at its highest point above the horizon," (De Lisle.) In these facts we have strong evidence of the correctness of an observation already made—namely, that the miasma is united with and suspended in the air by aqueous vapour, which, falling in the form of dew, carries down along with it the deleterious miasmatic particles. Koino-miasmata maybe arrested in its progress or passage from . its source to other parts, by whatever is capable of impeding and intercepting the progress of aqueous vapour. Thus the interposi- tion of a dense forest, of a high wall, or fence, of a chain of elevated hills, in short, of any mechanical obstacle of this kind, has been known to protect the inhabitants of villages, of camps, of convents, and of single habitations, from the pestiferous influence of neigh- bouring marshes. De Lisle relates several very remarkable facts illustrative of this observation, (Monfalcon, Bancroft.) A convent, situated on Mount Argental, near the village of St. Stephano, was, for a long time, remarkable for its salubrity;, until the trees' by which it was surrounded were cut down, when it became extremely sickly. From the same circumstance, miasmata are sometimes confined by obstacles of this kind, and so accumulated in particular localities, as to acquire a high degree of concentration and power. Marshes surrounded with dense forests, in warm climates, have often given 56 MIASMATA. unequivocal illustration of this fact. The same effect, in causing a stagnation and accumulation of miasmata, has been observed inmost situations environed by high hills. In some of the valleys in the mountainous regions of South America, malaria are thus accumulat- ed to a degree which gives them the utmost virulency, while the surrounding elevated parts are entirely free from miasmal diseases. This is remarkably the case of Acapulco, which, as Dr. Macculloch* observes, may be regarded as a striking instance " ofthe imprison- ment of malaria by hills." It is in this way, too, says this writer, that we "may explain the peculiar virulence of jungles and pine swamps, and even of woods every where." Considerable diversity of opinion has been expressed as to the distance to which miasmata may be diffused from theic source, in a state of sufficient concentration, to produce fever. In a quiescent state of the atmosphere, the sphere of activity is, probably, much more limited than has been generally supposed. Bancroft thinks, that they are rarely carried beyond a quarter of a mile, even by un- obstructed currents of air, in a state sufficiently active to produce fever; and he adduces several observations which seem to confirm this opinion. Unquestionably, however, currents of air passing over marshes, often convey the miasmata, which arise from them, to a very considerable distance—sometimes several miles, in a state of concentration fully adequate to the production of their usual de- leterious effects on the human system. " In Italy," says Dr. Mac- culloch, " the poisonous exhalations of the lake Agnano reach as far as the convent of Camaldoli, situated on a high hill, at the distance of three miles, proving that thus far, at least, malaria can be convey- ed by the winds." The account of the thirty Roman noblemen mentioned by Lancisci, is an interesting and striking illustration of this fact. They were sailing near the mouth of the Tyber, on a party of pleasure. Suddenly the wind shifted, and blew over the putrid marshes. Twenty-nine out of the thirty were soon seized with intermitting fever. The effects, often truly frightful, of the harmattan, after becoming loaded with the pestilential effluvia of the swamps of Benin, afford also a strong illustration of this fact From this circumstance, it not unfrequently happens, that those who reside on the leeward margin of marshes, or sluggish streams, are extremely harassed by miasmal diseases,—while those who sojourn on the windward side, remain almost entirely exempt from these "affections. Dr. Macculloch relates an instance from his own obser- vation, which strikingly illustrates this fact. " An army was en- camped in a very pestiferous plain, yet the health of the men did not suffer, because, being near the shore, the sea-breezes predomi- nating at that season, swept back the malaria into the interior country. From some cause, the encampment was transferred to another point, without recollecting that the change of the regular winds was * An Essay on the Production and Propagation of Malaria, &c. MIASMATA. 57 approaching. They did commence—sweeping in a new direction across the plain; and, within a few days, many thousand men were disabled or destroyed." During the autumns of 1820, '21, '23, and '24, there was scarcely a family between the eastern shore of the Schuylkill and the city of Philadelphia, that did not suffer from intermitting and remitting fevers; whilst among the inhabitants of the western shore, and of the high grounds a short distance back, there was, comparatively, but little sickness. The cause of this difference manifestly consist- ed in the course of the wind, which, during the periods here men- tioned, as indeed is generally the case, blew almost continually from the west, north-west, or south-west; and thus swept the miasma, which was generated along the oozy borders of the Schuylkill, in an eastern direction. Violent storms, and copious showers of rain, tend powerfully to free the atmosphere from koino-miasmata. The former violently disperses them, and the latter sweeps or washes them down to the surface of the earth. Nothing is more common than to find mias- matic epidemics to remit immediately after copious floods of rain or violent storms, (Rush, Bancroft, Monfalcon.) A humid air is a much better vehicle for the transportation of miasmatic exhalations, than a dry one. The particles of the mias- matic poison attach themselves to the humidity of the air, and are thereby carried along by currents of wind. It is to be remarked, however, that, although atmospheric humidity appears to favour the dissemination and action of miasmata, yet observation would seem to show that when these effluvia pass over a surface of water, they become absorbed, or in some way lost. This circumstance may, in part, account for the short distance assigned by Bancroft to the dis- semination of miasmata from their source; for in all the examples which he adduces in support of this opinion, the miasmata were con- veyed over bodies of water. II. Idio-miasmata.—This variety of miasmata is generated by the decomposition of the matter of perspiration, and the other ex- cretions of the animal body; and hence it most frequently occurs in the confined and crowded novels of the poor, in crowded jails, ships, hospitals, and wherever many individuals are confined in apartments not duly ventilated. From "an inability to procure separate dwell- ings, the poor are generally obliged to take up with small apartments, into which two or three families are often crowded; and in order to save fuel, and indeed frequently from the total want of fuel, every access of the external cold air is carefully cut off. Add to this the filth and want of proper changes of clothing, almost inseparable from extreme poverty, and you have a combination of circumstances pe- culiarly calculated to generate a miasma, by the putrefactive decom- position of the animal exhalations with which the air and every article of clothing in such apartments must be saturated. It is chiefly during the cold season of winter that this variety of mias- Vol. I.—8 58 MIASMATA. mata is generated. When the weather is warm, the air of crowded and filthy apartments is constantly renewed by the doors and win- dows being kept open, and the accumulation and stagnation of the animal exhalations thereby prevented. Dr. Smith observes, that this miasm is especially apt to be generated in the apartments of the sick, particularly "of those who are labouring under the typhus state of fever."* It may be observed, however, that the exhalations which emanate from the body in a state of disease, and which pos- sess the power of producing the same disease as that, under whose influence they are evolved, cannot, with strict propriety, be ranked with the present class of miasmal poisons. They belong to the con- tagions. I would restrict the term idio-miasma, to those morbific effluvia, which are generated by the decomposition of the animal secretions, whether formed in a state of health or disease, and to the ordinary exhalations from the body, when accumulated in such a manner as to deteriorate the atmosphere of confined rooms, if these be really capable in themselves, and without decomposition, of ex- citing fevers. Idio-miasmata are always quite limited in the sphere of their influence. Beyond the room or habitation in which they are gene- rated their operation cannot extend; unless, indeed, they are absorbed or adhere to articles of clothing, and are conveyed abroad in a state of sufficient activity to act on the human system. Whenever fever is found to spread from a source of idio-miasmata, it is in conse- quence, doubtless, of the generation of a new contagious miasm by the disease, which is produced in the first instance by the idio-mias- matic poison. I am well aware that this opinion involves what has been declared a manifest inconsistency—namely, the origination of a contagious disease by a common or general exciting cause. All such objections, founded merely on speculative inferences, may be met by facts, which must stand good, however irreconcilable they may appear to be with the dogmas of philosophy, or with admitted • principles. It is a fact, for instance, that typhus may be originated by the miasm resulting from the decomposition of the secretions or exhalations of even healthy individuals, crowded and confined a long time in narrow and unventilated apartments. And, that although not necessarily a contagious malady, typhus may, under peculiar cir- cumstances, generate a specific virus which is capable of exciting the same disease in others, is a fact supported by a mass of testimony whch cannot be, reasonably, rejected. "There are few physicians," says one of the most eminent medical writers of the present day't " who believe that epidemic or endemic fevers arise from specific con- tagion though facts daily teach us that typhus, yellow fever, dysen- tery, &c occasionally, and under particular circumstances Uve out a something, (call it what you please) which proiw;'a Tmilar » Elements of the Etiology and Philosophy of Epidemics p 52 t Dr. James Johnson, Med. Chir. Rev. vol. VII. (1825 ) o 65 MIASMATA. 59 disease in the healthy stander-by, who happens to come within its range. If we may venture to prognosticate, we would anticipate that this will be, as it assuredly now is, the more general opinion among practitioners." From the circumstance of this variety of miasmatic poison "be- coming innoxious when diffused in the atmosphere, even a few feet beyond the apartments in which it is generated," none of the forms of disease, which it is capable of producing, are apt to occur epidem- ically. Typhus, nevertheless, has been known to occur in a manner well entitled to the name of epidemic. The late widely spread epi- demic of Ireland was surely strongly characterized in its progress and extent of diffusion b)' every feature which can give to diseases the character of an epidemic. Though engendered and nursed in the lap of wretchedness and poverty, it did not, in its desolating sway, fall exclusively upon those who were suffering under the dis- tressing privations of penury. Its fatal visitations were abundantly made to the ample and airy habitations of plenty and comfort, and almost— ——— aequo pulsat pede pauperum tabernas Regumque turres. The question here occurs: If "idio-miasmata becomes innoxious by being diffused in the atmosphere even a few feet beyond the apartments in which it is engendered," how can typhus, which is manifestly originated by this effluvium, become epidemic, or be pro- duced in large and well ventilated dwellings remote from the usual sources of this miasm? Is it by the idio-miasmata attaching itself to the clothes of individuals, or to other substances by which it may be conveyed from one to another place? If this be admitted, then idio- miasma must possess the character of a contagion. Is it not more probable, that in the majority of instances of this kind, the disease is propagated by a specific virus, generated by morbid secretion, and conveyed as other contagions of an aeriform character are conveyed? It does not seem probable that idio-miasmata can be disseminated by fomites. If it can be so disseminated, it must possess all the charac- teristics of a veritable contagion. Of the relations of Miasmata to the Animal System, fyc. Having given an account of the physical character and conditions under which the two infectious effluvia, koino and idio-miasmata, are evolved, I proceed to the consideration of their relations, as morbific agents, with the human system, as well as with each other. Upon this subject I stand largely indebted to the ingenious and truly philosophical work of Professor Smith, of New York; for although I have long since entertained similar views in relation to the com- bined agency of these miasmal poisons in the production of fevers, yet the enlarged, systematic, and precise views taken of this subject 60 MIASMATA. by Dr. Smith, have afforded me some new and interesting insights into this part of the etiology of fevers. The class of fevers arising from koino-miasmata are very distinct in their general character, and we may presume, in their essential natures, from those which are the result of idio-miasmata. The former give rise to intermittent, remittent and bilious fevers; and the latter miasm is the source o£typhus,a.nd the low nervous fevers of former writers. The deleterious power of koino-miasmata is manifested not only by the violent and fatal fevers which they are known to produce so abundantly, but also by the more slow inroads they make on the physical and moral condition of those unfortunate beings, who are habitually exposed to their influence. The indigenous inhabitants of marshy districts, in warm climates, present an aspect of suffering and wretchedness from this cause, which is well calculated to draw forth the commiseration of those who are more fortunately located. Continually exposed to the deleteribus influence of these baneful ex- halations, man, in such situations, exhibits a state of feebleness and early decrepitude, strongly indicative of a broken-down constitution, and deep, irremediable chronic disease. So deep and pervading, indeed, are the effects of malaria on the human system, that it never fails to debase, in a remarkable manner, both the physical and moral constitution of a people, who through successive generations, reside in situations abundant in perennial sources of miasmata. Not only does the stature and symmetry of the body suffer conspicuous dete- rioration, but the mind becomes torpid, feeble, pusillanimous, and the moral sentiments debased. But while such chronic and constitutional effects are wrought by the habitual endurance of koino-miasmata, the system loses its sus- ceptibility of being excited into those violent commotions of febrile action, which this agent is so apt to produce in individuals less accus- tomed to its impressions. The natives of marshy districts are com- paratively much more rarely affected with the higher grades of miasmal fevers, than those who are only occasionally brought within the sphere of its influence. In the former the agency of this poison proceeds as it were by a slow and concealed combustion; whilst in those who are not accustomed to its influence, its effects burst out in a raging and rapidly consuming flame. There can be but little doubt that koino-miasmata varies in its powers, and often very considerably, according to various circum- stances, in point of locality, and the relative proportions of the ani- mal and vegetable matter which, supply the materials for its compo- sition. Dr. James Johnson, whose authority I am always disposed to respect, has expressed his belief in the occurrence of such diver- sities in the peculiar morbific powers of this agent. « The fever of Batavia," he observes, " differs from the fever of Walcheren—the fever of Antigua, from the fevers of the Ganges—and all these dif- fer materially from the plague of the Levant." That certain coun- MIASMATA. 61 tries and localities have an especial tendency " to generate one mode or variety of fever; while in other situations, some other variety as exclusively prevails," is an observation founded on abundant testi- mony of unquestionable authority. In Germany, intermittents almost universally assume the tertian type; in Italy, the quotidian type greatly predominates; and in Hungary, paludal fevers are pecu- liarly apt to be attended with petechia?. " The fevers of the Pontine marshes are noted for the shortness of their intermissions; whilst Holland is not less remarkable for the variety of the types than the slow progress of the fevers. In Spain, as in Africa, the West Indies, and the southern parts of the United States, the black vomit and the yellowness of the skin are similarly characteristic symptoms."* Even in localities situated within a short distance from each other, the most remarkable difference occurs in the character of the fevers which they engender. Thus, " the fevers of Walcheren," says Dr. Macculloch, " differ materially from those of Bresken on the opposite shore of the Scheldt; and in France those of Rochefort differ as completely from those of the Lyonnais." It cannot be presumed that the relative proportions of animal and vegetable matter should be the same in different localities, and equally improbable is it that the same kinds of thene materials should be present in the different situations where miasmata are generated. There must be great diversity in both these respects, and a corre- sponding diversity in the essential morbific qualities of the miasmata evolved from them. I have already mentioned the ex-periments of Majendie in relation to the effects of putrid animal substances on the animal system. From these it appears, that " different kinds of flesh, when in a putrid state, produce different effects on the animal economy,"t and it is, therefore, reasonable to conclude that- mias- mata will differ in their powers according to the greater or less pro- portion and kinds of the animal and vegetable matters concerned in their production. The influence of koino-miasmata on the human system, like that of other general causes of disease, is much under the control of the physiological state of the animal economy, of idiosyncracy, of tem- perament, predisposition, and of accidental external causes. Thus of a number of individuals exposed for a certain time to the same miasm, some may become affected with intermitting fever, others with mild remittent fever, some with malignant bilious fever, some with bilious colic, some with dysentery, and others, perhaps, will escape the disease entirely. The influence of high atmospheric temperature in predisposing the system to the deleterious impressions of miasmata is, proba- bly, very considerable. Long continued exposure to solar heat appears to have an especial tendency to affect the biliary organs, and * An Essay on Malaria, &c, by John Macculloch, M. D. f Journal de Physiologie, Janvier, 1823. 62 MIASMATA. to render the system generally, irritable. These conditions, it may be presumed, are peculiarly favourable to the morbific influence of malaria; and it is not improbable that they sometimes contribute, in a considerable degree, to render the miasmatic fevers of intertropical or hot climates, so peculiarly violent and dangerous. Dr. Maccul- loch dwells much on " errors of diet" as a predisposing cause of the miasmal fevers. It would appear, that the free use of animal food, in tropical climates, is peculiarly calculated to favour the morbific influence of miasmata; and this is said to be especially the case when the animal food is taken " in the middle of the day, or frequently in one day." On examining Niebuhr's narrative, says Dr. Macculloch, " it is most apparent that the deaths of his companions were the con- sequences of gross feeding." " On this question," says the same writer, " there can perhaps be no better evidence than the opinions and practices of the intertropical nations themselves, among the mass of whom this subject seems well understood; while in many coun- tries it is a caution actually often given to Europeans by the natives, though most generally neglected by them. It is, probably, from long experience, in some measure, of its advantages, as well as from more obvious causes, that a vegetable diet is so general throughout the aborigines of the torrid climates; while it is doubtless from prin- ciple, also, that among the people of Africa, to the northward, at least, the sole or the principal meal is supper." The class of diseases produced by koino-miasmata, if we take into view their various modifications, is by no means limited in its range. The most simple form of disease arising from this cause is the inter- mittent fever. In proportion as this febrific effluvium increases in potency, so does it produce fevers of a higher and more violent grade. The range of activity of this miasma extends from the sim- ple tertian of the temperate latitudes to the malignant and fatal plague of the East, or the scarcely less fatal bilious fever of Batavia. Besides general fevers—assuming an endless diversity of charac- ter in different seasons and climates, koino-miasmata produce, also, various other affections, both local and general. Dysentery, cholera, and diarrhoea, are enumerated among the maladies produced by ma- laria. It may be doubted, however, whether miasmata, by itself, without the co-operation of other causes, has any particular tendency to excite these affections. I apprehend, that in many instances occurring in malarious districts, as elsewhere, atmospheric vicissi- tudes, or cold, exerts no small degree of influence in determining the disease upon the alimentary canal. During the autumn of 1814, one-fourth, perhaps, of the men of four regiments encamped near Baltimore, were affected with intermitting and remitting fever in the month of September. The weather was remarkably warm, equable and dry. The months of October and November, however, were rainy, extremely variable in temperature, and the majority of the men, who were previously lodged in covered rope-walks and houses, were now encamped in tents. A week after the rainy and MIASMATA. 63 cold weather set in, dysentery and diarrhoea began to appear abun- dantly, and in the course of three weeks more, there were but very few cases of intermitting or remitting fever, but more than eight hundred cases of dysentery. Nevertheless, the capability of mias- mata of producing these forms of intestinal disease by its own un- aided powers, is not to be questioned, although it is, I think, equally evident, that the co-operation of sudden changes of atmospheric tem- perature, or cold, is especially calculated to enhance the tendency of the miasmata to occasion these diseases. From these remarks, cho- lera ought to be excepted, for the cholera of India, at least, is most undoubtedly the product of a miasmatic agent. Dr. Macculloch mentions tic douloureux as a common consequence of the influence of miasmata,—more especially in Italy; and the occurrence of periodical hemicrania from this cause, is by no means unfrequent, even in our own climates. In truth, there is scarcely a malady that may not be produced or stimulated by the operation of malaria on the human system. The period which intervenes between the reception of koino- miasmata and the first manifestation of its influence on the human body, is extremely various. Of many persons exposed to it at the same time, some may be immediately affected, others in a few days, some not until several weeks have passed, whilst others may remain free from its effects a still longer time. As the powers of koino-miasmata most probably vary consider- ably in different countries and localities, it may be inferred, as has already been observed, that the fevers which they produce are im- pressed with a corresponding diversity in their character; an obser- vation would seem to confirm this inference. Dr. Smith thinks, that whatever external or general diversities may occur in fevers pro- duced by this miasma, " their pathology or essential nature is every where the same." This is highly probable; for the diversities in question would seem to depend more on the mere grade of violence, local affections, and general course of these fevers, than on any radi- cal difference in their essential pathological conditions. Upon this point, however, it becomes us to speak with diffidence, as this ques- tion is not be solved by mere closet inferences and reasonings, but by close observation and careful experience, in relation to these fevers as they occur in various countries, climates, and localities. How far a mixture, or the combined agency of koino and idio- miasmata, may operate in producing novel or anomalous varieties of fever, it is impossible to say; but that such a combination does sometimes occur, and give rise to fevers of a peculiar or mixed cha- racter, will scarcely be doubted by any one who has given due atten- tion to this interesting subject. Professor Smith, to whose work I have already so frequently referred, has given this subject a comprehen- sive and minute consideration, and to whom, indeed, the credit is due for introducing this interesting point of etiology to the notice of the profession. " Let us suppose," says Dr. Smith, " the circum- 64 MIASMATA. stances in which typhus originates, to occur in summer, sucftM the crowding of individuals into small apartments, badly ventilated, and rendered offensive by personal and domestic filth. Ihese causes would obviously produce typhus in its ordinary form. But suppose there exist at the same time, those exhalations which occasion plague and yellow fever, or intermittent and remittent fevers. Under such circumstances, we should not expect to see any one of those diseases fully and distinctly formed, but a disease of a novel or modified cha- racter." There exists no doubt in my mind, of the correctness of Dr. Smith's observation, that the late Banker street fever in New York, as well as the peculiar fever which prevailed among the blacks in this city, a few years ago, was engendered by the united influence of these two miasmal poisons. 1 once had a striking illus- tration of the anomalous and fatal character which the united action of koino and idio-miasmata are apt to impart to fever. During the fall of 1814, while attending in the capacity of regimental surgeon, in the encampment at Baltimore, ten men affected with mild remit- ting fever, were lodged in a room of confined dimensions, and as the weather was cold, the room was kept pretty warm by fire, and the doors and windows as little opened as was admissible. The adjoin- ing room was exceedingly crowded with invalids, and but little attention paid to cleanliness and ventilation. In a short time seve- ral cases of fatal typhus occurred in this room. Soon after this, the patients who were affected with intermitting fever in the next room, manifested new and more alarming symptoms; blood began to ooze from their gums; extreme tenderness of the epigastrium occurred; the intellect was but little disturbed; the eyes were dull, watery, and staring; the temperature of the skin and the pulse nearly natu- ral; the animal powers so little prostrated, that one of the men died a few minutes after he had been sitting up with his back leaned against the wall of the room. They were all immediately removed to the Baltimore Hospital, and all except one died in a few days. There can be no doubt, that this peculiar modification of febrile dis- ease was the result of the impressions of idio-miasmata (engendered in the house,) made on systems already under the morbific influence of koino-miasmata. Sect. V.—Of Contagion. By a contagion is understood a deleterious agent secreted by the animal body in a state of disease, which, when brought to act on a healthy individual, will produce a disease specifically similar to the one from which it derives its origin. Contagions occur under two distinct forms, and may therefore be divided into two varieties: viz. 1. Those which consist of a palpable matter or virus; and, 2. Those which consist of an imperceptible effluvium. The chronic contagious maladies are propagated exclusively by a palpable virus, and consequently always by actual contact. Those acute contagious CONTAGION. 65 diseases which are not attended by a specific local affection, or an exantheme, are, on the other hand, exclusively propagated by a morbific contagious effluvium, and, by consequence, solely through the medium of the atmosphere. Those acute diseases, which are essentially connected with a specific local affection, or an exan- theme, are communicated bo..' by a palpable virus, and by an im- perceptible effluvium, and consequently both by actual contact and through the medium of the atmosphere. We perceive, therefore, that of the extremes of a purely local, and a purely general malady, there is, on the one hand, communication of the disease solely by a palpable matter, and, on the other, by effluvia only; and that where the local and the general affections meet in the same disease, as es- sential concomitants, (in the exanthemata) there the two modes of propagation also obtain.* It must be observed, however, that though in a practical point of view we may properly adopt these distinctions between contagions communicated by contact and through the medium of the atmo- sphere, yet, in reality, an actual contact must, necessarily, always occur between the contagion and the individual, before it can possi- bly produce disease, whether the contagion be a palpable matter, or an imperceptible miasm. The only material difference consists in the mode in which this contact is effected. One of the most remarkable peculiarities of contagious diseases, is their inherent and undeviating tendency to preserve their essential individuality, under whatever circumstances of age, sex, constitution, temperament, modes' of living, climate, and place, they may occur. Thus, the small-pox of the present day, differs in no essential cir- cumstance from the same disease, as it was observed and described by Rhazes more than eight centuries ago; and the itch has changed in nothing since the time of Galen. Any certain contagion can, so far as we know, produce only one disease; and if the system has become insusceptible of such disease, its peculiar cause is no longer a mor- bific agent in relation to that system. The laws of the acute contagious diseases differ entirely from those which govern the rise, progress and declension of the chronic con- tagious affections. The former observe the utmost regularity in all these respects. The rise, advancement and decline, in short, the whole series of essential phenomena, are governed by laws as stead- fast as those which regulate the motions of the planets. The latter class of diseases, on the contrary, are extremely irregular in their course, having no definite period of duration, nor established order and duration of the successive phenomena of their course. * This arrangement is adopted from Dr. Hosack's very lucid classification of contagions and their peculiar diseases. There is no writer of the present day, whose views upon the character and arrangement of this class of maladies, de- serve higher respect and attention than those which have been promulgated by Dr. Hosack. Vol. I.—9 66 CONTAGION. The power which the acute contagious diseases have of destroy- ing the susceptibility of the human system, to the subsequent influ- ence of their specific cause?, constitutes one of the most remarkable and mysterious characteristics of this class of maladies. In this re- spect, they differ as far from the chronic affections of this kind, as they do from the febrile diseases produced by general or non-con- tagious causes. In consequence of this law of acute contagious diseases, no malady of this kind can ever relapse during the period of convalescence. Considerable diversity of sentiment has been expressed in relation to the distance to which contagious miasmata may be dispersed from their source, in a state of sufficient activity to generate disease. That their sphere of activity is very limited, however, has. been abundantly demonstrated, both by direct experiment and observation. The experiments of Dr. 0. Ryan, professor of physic in the college of Lyons, prove that the contagious miasm of small-pox does not extend more than a few feet beyond its source.* The most malig£ nant contagions are rendered inert and harmless by being diffused in the atmosphere, and even by diffusion in the air of a well ventilated apartment. Ventilation diminishes the activity of contagious effluvia, simply by diffusing the miasm in a large portion of atmospheric air, in consequence of which, those who become exposed to it, receive it in weak and inefficient doses. Contagions are perpetuated and conveyed to great distances from their source, by being absorbed by, and attached to, various sub- stances, such as clothing, furniture, bedding, &c, with which they are often transported even across the ocean. Animal substances, such as wool, hair, and articles manufactured from them, are said to retain contagious matter with the greatest tenacity. The more the sub- stances which have become saturated with contagion are kept from the access of the open air, the more virulent ansWictive will be its powers when it is brought to act upon the huniHi system. Thus, articles of clothing, after having been impregnalpl with contagious virus, will retain the power of infecting much longer, and in much greater intensity, if they are kept confined in close rooms, or locked up in chests or closets, than when they are freely exposed to the open air. It is by articles of this kind, locked up in trunks, that the small-pox, and other contagious maladies, have been conveyed to distant parts of the world in ships, although no person on board may have been sick with the disease during the voyage. The arti- cles which are thus imbued with contagious virus, are called fomites. It was the opinion of Cullen, that contagions are more powerful when they are thus lodged in fomites, than when they arise imme- diately from the human body, or when in a separate state. The same opinion is expressed by Dr. Lind. The influence which peculiar atmospheric constitutions have on * Rees's Cyclopedia; article Contagion. CONTAGION. 67 the activity of contagions, and on their tendency to dissemination, is a subject as interesting as it is inscrutable. The most careless observation is sufficient to convince any one, that there exists in the varying constitutional, or perhaps accidental conditions of the atmo- sphere, a powerful modifying principle in relation to the powers of contagious agents. At times, it would seem impossible for a con- tagious disease to extend the sphere of its ravages; for, although spo- radic cases may occur here and there, yet no neglect in relation to proper seclusion, will enable the disease to assume an epidemic or endemic character. During other periods, on the contrary, the acci- dental importation of fomites, or the occurrence of a case of conta- gious disease, acts like a spark of fire thrown among combustible materials, and speedily spreads disease extensively among the people. The same powerful atmospheric influence shows itself in the diver- sity of character, in relation to the grade of violence, malignit}r, and general diathesis, which the same malady is observed to assume at different periods of its prevalence. That these things depend on some modifying agency of the atmosphere, there can exist but little doubt. What this conditon of the atmosphere consists in, it seems impossible to ascertain; it is probable, however, that it has no imme- diate connexion with either the temperature or the hygrometrical state of the air; for, with the exception of typhus, which is mani- festly favoured by cold weather, the contagious diseases of every kind prevail equally during the heat of the summer and the cold of the winter. The mode in which contagions are either favoured or retarded in their progress by atmospheric constitutions, consists, probably, not in any influence which they may exert immediately on the powers of the contagion, but rather, perhaps, in their ten- dency to modify the human constitution, so as at one time to render it peculiarly susceptible of the influence of the contagion, and at another to diminish, or for a time to annul, the natural predisposi- tion to its operation. Of the primary source of contagion we know but very little. It is probable that each contagious disease was at first developed, inde- pendent of contagion, by the accidental concurrence of various cir- cumstances, which, in the infinite series of such contingencies, may not again occur for many centuries. That a disease may be origi- nated by the concurrence of general causes, without the agency of a contagion, and which may afterwards communicate itself to others, by a specific virus of its own elaboration, we have a familiar example both in typhus fever and in itch. There is reason to believe, indeed, that various contagions have been thus produced, which have long since passed away from the face of the earth;* and it is not an idle » * The sudor anglicanus, so accurately described by Caius, appears to have been a highly contagious disease. It visited England five times in the period of seven years, and swept off a vast number of victims by its fatal violence. In many instances, those who were affected with it died within an hour, and few who 68 CONTAGION. conjecture to say, that new contagions may hereafter arise, which, after having exhausted their power on mankind, may again disap- pear for ever, or until a similar concurrence of causes, which at nrst evolved the contagion, again occurs. It is an interesting fact, that contagious diseases sometimes ori- ginate in the lower orders of animals, and are afterwards communi- cated to the human species. Hydrophobia and the vaccine disease are familiar examples of this kind. Professor Remur has published some observations which go to show that other diseases, such as the virulent coryza of horses, the plica of long-haired animals, and the gangrenous inflammation of the spleen which occurs in cows, may be communicated by immediate contact to man. The following rules have been recommended for preventing the spread of contagious maladies to those who are obliged to approach patients labouring under diseases of this kind (Haygarth.) 1. "The chamber in which the patient lies, must be kept clean and freely ventilated. No bed curtains must be allowed to be drawn around the patient." 2. "Dirty clothes, utensils, &c. should be often changed, and im- mediately immersed in cold water; and wrashed clean when taken out." 3. "The discharges from the patient must be instantly removed; and the floor around the patient should be rubbed clean once a day with a wet cloth." 4. "Avoid the current of the patient's breath, as well as the efflu- via which ascend from his body, and from the evacuations." 5. "Visitors ought not to go into the patient's chamber with an empty stomach; and in doubtful circumstances, on coming out they should blow from the nose and spit from the mouth any contagious poison which may adhere to these passages." Although it is quite certain that contagions will adhere to and im- bue various substances, especially clothing, so as afterwards to repro- duce the same disease, at a distance from their source, and often a long time after they had been generated; yet it seems to be well as- certained, that such substances, (clothing) can rarely be so greatly imbued with contagion by a slight and transient exposure to the poison, as to be capable, afterwards, of producing disease in the healthy. The clothes of transient visitors, for instance, will scarcely ever imbibe sufficient contagion to communicate the disease to others. Dr. Clark affirms, "that in eighteen years of medical practice, he never communicated the contagion of small-pox nor of scarlet fever to any one, although he had frequently, on the same day, visited many patients sick with these diseases, and in their most malignant forms." sunk under its malignity suffered longer than four or five hours. It has not been known to occur for several centuries past, its contagion having long since become wholly extinct. CONTAGION. 69 Mere ventilation is inadequate to destroy the contagion deposited in fomites. To effect this important object, a great variety of means, such as exposing them to various vapours and fumes, have been devised. Without enumerating the different disinfecting agents which have been successively brought forward and again rejected, it will be suf- ficient to mention those which experience has shown to possess active powers in this respect, and which are now relied on as unquestion- able disinfecting agents. The nitrous acid vapours have been much employed for disinfecting ships and houses in which contagion has been found to exist. Such was the evidence brought forward of the efficacy of the nitrous acid fumes in purifying infected places and fomites, that the British parliament voted a national donation of five thousand pounds to Dr. Carmichael Smith for the discovery. This vapour is readily obtained by mixing with powdered nitre, in a cup, a little of sulphuric acid, and applying gentle heat with a lamp. At present, however, chlorine, and the chlorides of lime and soda, are regarded as decidedly the best disinfecting agents we possess. M. Labarraque's disinfecting soda liquid is a compound of soda and chlorine, and its efficacy in destroying infectious matter, has been con- clusively demonstrated. "It is now much used in removing the offen- sive odour arising from drains, sewers, or all kinds of animal matter in a state of putrefaction. Bodies disinterred for the purpose of judicial inquiry, or parts of the body advanced in putrefaction, may, by its means, be rendered fit for examination; and it is employed in sur- gical practice for destroying the fetor of malignant ulcers. Clothes worn by persons during pestilential diseases, are disinfected by be- ing washed with this compound. It is also used in fumigating the chambers of the sick, for the disengagement of the chlorine is so gra- dual, that it does not prove injurious or annoying to the patient. In all these instances chlorine appears actually to decompose the nox- ious exhalations by uniting with the elements of which they consist, and especially with hydrogen." "Pure chloride of soda is easily prepared by transmitting to satura- tion a current of chlorine gas into a cold and rather dilute solution of caustic soda. In preparing the disinfecting liquid of Labarraque, it is necessary to be exact in the proportion of the ingredients em- ployed. The quantity used by Mr. Faraday, founded on the direc- tions of Labarraque, are as follows: Dissolve 2800 grains of crys- tallized carbonate of soda in 1.28 pints of water, and through the solu- tion contained in a Wolf's apparatus, transmit the chlorine evolved from a mixture of 967 grains of sea-salt and 750 grains of peroxide of manganese when acted on by 967 grains of sulphuric acid diluted with 750 grains of water."* * Turner's Elements of Chemistry. 70 GENERAL COURSE, &.C. OP FEVER. CHAPTER III. OF THE GENERAL COURSE, TYrE, AND STAGES OF FEVER. The series of phenomena which intervene between the commence- ment of a fever, and its termination in convalescence, constitutes what is technically called its course. The course of a fever is either intermitting, remitting, or continued, according as its phenomena intermit, or remit, or are continuous. The series of phenomena which constitute the course of a fever, may be divided into six periods or stages; viz. the forming, the cold, the hot, the critical, the declining, and the convalescing periods. It should be observed, however, that these stages are not always distinctly marked, in violent and continuous forms of fever, although very few fevers occur in which the primary stage of oppression, the stage of excitement, and the period of declension, may not be dis- tinctly observed. The febrile paroxysm of an intermitting fever offers the most distinct exemplification of the successive changes or stages which occur in the course of a fever. 1. The forming stage—the stadium prodromorum includes the period which intervenes between the first impressions of the febrific cause, and the actual commencement of the febrile phenomena. This period is characterized by a variety of feelings or sensations, which, though manifesting a deviation from the healthy condition of the sys- tem, do not constitute any definite state of disease. These constitute the premonitory symptoms. Their duration is very various; and in some instances, though very rarely, they are entirely absent—the disease making its attack at once, without any previous manifesta- tions of its approach. This is most apt. to occur in fevers of very vigorous reaction, and in such as are of a malignant character. The longer or shorter duration of the premonitory stage depends, how- ever, probably as much on the different powers of vital resistance, as on the difference in the degree of concentration or activity of the remote febrifie cause. The whole train of premonitory symptoms may be regarded as the result of the struggle between the vital pow- ers and the febrific cause. If the cause be feeble, and the vital re- sistance great, its first impressions may give rise to some unusual or unpleasant sensations, until the system finally triumphs over its influ- ence, and disease be obviated. When the relative powers of the cause and the vital resistance are more nearly balanced the struggle^ between them may be prolonged, until the latter yield and disease be developed; and where the system resists feebly, whilst the fe- brific cause acts with energy, the contest will probably be short, and the fever occur suddenly, with violent symptoms There exists, nevertheless, in almost every febrific cause, a natural tendency to GENERAL COURSE, &C OF FEVER. 71 produce some peculiar premonitory symptoms, although the general and most conspicuous of these phenomena are pretty nearly the same in almost every form of febrile disease. In general, those fevers which are apt to run through a protracted course, have a much longer train of premonitory symptoms than such as are violent and of short duration. Thus, the premonitory period is almost uniformly much more protracted in typhus and typhoid, than in the synocal fevers. The following are among the most common symptoms of this initial period of febrile affections: loss of appetite; disturbed sleep; yawning, stretching, lassitude, wandering pains in the limbs and back; an unpleasant sensation in the stomach; aharsh and dry skin; irregularity of the bowels; a general feeling of mal-aise; nausea; eructations; interruptions of the ordinary habits aud appetites; fret- fulness; discontent; slight headach; slight creeping sensations of cold; the drying up of old sores; tremors of the extremities; changed expression of the countenance; giddiness; and perhaps some other slight deviations from a state of perfect health, or the ordinary habits and feelings of the individual. If we examine the symptoms of this stage in the usual order in which they occur, we will perceive that the nervous system is the first that suffers; this is manifested by the lassitude, languor, and slight transient pains which usher in this stage. Next, the digestive organs are brought into a state of slight suffering; and finally the skin. The heart and arteries appear to be the last organs which are brought into morbid action in the development of fever. 2. The cold stage.—Nearly all fevers commence with more or less sensation of chilliness. The feeling of cold is not always at- tended with an actual subduction of sensible temperature. In some instances, the skin of the patient feels warm to the touch, whilst he is shivering under the severest sensations of cold. It is manifest, therefore, that in such cases, the feeling of cold depends in reality on an altered or morbid condition of the sensibility of the skin, in consequence of which its power of perceiving (if I may use the ex- pression) the ordinary degree of animal temperature is diminished. In most instances of febrile chills, however, there occurs an actual reduction of the temperature of the surface, especially of the hands and feet. Not unfrequently these parts feel quite cold to the touch of a healthy person, whilst the surface of the trunk and the forehead are of the natural temperature, and sometimes apparently even higher; although the sensation of chilliness experienced by the pa- tient will be diffused throughout his whole system. The chills are attended with a pale, contracted, and dry state of the surface; the volume of the body is diminished; the respiration confined, irregu- lar, anxious, and oppressed, attended frequently with a short (fry cough; the head feels confused; the tongue is dry, attended some- times with great thirst; the pulse becomes extremely small, frequent, and feeble; nausea often occurs, and sometimes vomiting. The sense of chilliness is usually diffused over the whole body; though in some 72 GENERAL COURSE, &C. OF FEVER. instances, it is partial, and occasionally, limited to a small part of the body. In general, the more violent the chills are, the more vigorous will be the subsequent arterial reaction. As the cold stage o-radually subsides, the arterial reaction regularly rises, until chil- liness has wholly gone off, and the disease has entered into the— 3. Third, or hot stage.— This stage is characterised by what may be termed the essential phenomena of fever: viz. augmented heat, and a return of the natural fulness and colour of the surface; flushed countenance; a full, quick, frequent and vigorous, or a small, tense, quick and frequent pulse; throbbing pain in the head; eyes promi- nent and sensible to the light; a dry and hot skin; urine scanty and high-coloured; continued wakefulness, &c. These symptoms, with more or less intensity, continue for a longer or shorter period, until the acme of the febrile condition has arrived and the period of— 4. Crisis supervenes. By crisis, is understood, in the most gene- ral acceptation of the term, that period in the course of a fever at which it has arrived at its highest point, and a determination either to a fatal or a favourable issue takes place; and by which, therefore, the fate of the patient is determined. The period during which this decision occurs, is necessarily always short; and is almost uni- versally attended with some evacuation. The most common criti- cal evacuation of a simple febrile paroxysm, consists of a very greatly increased flow of perspiration, and hence the subsequent period during which this evacuation is continued, is called the sweating stage, but which I would call— 5. The stage of declension—stadium decrement i morbi.—This stage may be considered as commencing immediately after the fa- vourable crisis has taken place. In the rapid, continued fevers, and in a single paroxysm of an intermittent, one crisis only occurs; but in by far the greater number of protracted, and especially in remit- ting fevers, the crises continue to recur through the whole period of declension at every tertian exacerbation, until the disease is finally subdued. The duration of this stage is extremely various. In general, the period of declension will be pretty nearly in proportion to the period occupied in the progress of the fever to its acme. The space of time which is occupied by one paroxysm of a fever and its succeeding intermission, or which intervenes between the regular periodical exacerbations of fevers not paroxysmal, is called the revolution of a fever. The revolutions of fevers are various in point of duration; some fevers completing theirs in twenty-four hours, others in forty-eight, whilst others require seventy-two, and some even ninety-six hours. The form which a fever assumes, in this respect, is called its type; so that a fever which occupies twenty-four hours from the commencement of one paroxysm to another, is said to be of the quotidian type; whilst one which revolves every forty- eight hours, is of the tertian type; and when this period is extend- ed to seventy-two hours, the fever is of the quartan type; and a period of ninety-six hours, constitutes the quintan type. The quo- GENERAL COURSE, &C OF FEVER. 73 tidian, the tertian, and the quartan types, constitute the three principal and primary types of fevers; all of which are, however, subject to modifications, which may'readily mislead the careless observer, so as to confound them, or mistake one for the other, es- pecially the quotidian and the tertian. It has been observed, that in fevers of the quotidian type, the paroxysms generally come on in the morning—a circumstance which has been almost invariably verified in my own experience, and which is, indeed, so constant, that Cullen was induced to notice it in his definition of a quotidian. Tertiaas commonly come on towards noon; but they are much less regular, in this respect, than fevers of the preceding type. Two simple tertians sometimes go on contemporaneously, in the same patient; so that, instead of the pa- roxysms recurring only every other day, they occur daily, as in a quotidian. These cases are called double tertians, and are distin- guished from quotidians, by the paroxysms of the alternate days being similar in relation to the precise time of their occurrence, grade of violence, duration, and other circumstances. Thus the pa- roxysms on the odd days will perhaps recur at 9 o'clock in the forenoon, whilst those which happen on the even days will come on at 2 or 3 o'clock in the afternoon, so that, although each day has its paroxysm, the fever cannot be properly considered as a quotidian, but the contemporanenos progress of two simple tertians, the one having commenced a day sooner than the other. Fevers, however, rarely assume the double tertian type from their commencement. They usually begin and continue for some time, in the simple tertian type—the duplication occurring afterwards; and when the type thus becomes doubled, the new or accessory paroxysms are generally considerably milder than those of the original or simple tertian. It is asserted, that a double tertian seldom terminates without first assuming the single tertian type—the accessory or weaker paroxysm disappearing first.* There are other varieties of double tertians, mentioned by the older writers, such as the tertiana duplicata, in which two paroxysms occur every second day, and none on the intervening one; the hsemitritseus of the ancients, in which a paroxysm occurs daily, the intermissions or remissions between the first and second, the third and fourth, being much more prolonged than those which occur between the second and third, the fourth and fifth, &c. Au- thors also mention a triple tertian—tertiana triplex. The quartan type, also, has been known to assume similar modifi- cations. Double and triple quartans are mentioned in the books; as well as other anomalous varieties of this affection. Before I proceed to the consideration of the particular forms of fever, it will be proper to say something concerning crisis or critical days—a subject which, though but little regarded at the present * Richter's Specielle Therapie, vol. I. Vol. I.—10. 74 GENERAL COURSE, &C OF FEVER. day, appears to me entirely worthy of attention. It may, I think, be assumed as a safe principle, that doctrines or sentiments, concern- ing facts which are objects of mere observation and experience, cannot he wholly erroneous qr; illusory, after having obtained the entire confidence, through a series of more than twenty centuries, of a vast number of as accurate and devoted observers of nature as have ever adorned our profession. Without professing a belief in the correctness of the doctrine of crisis as it was taught by the ancients, and by many of the moderns, we may yet admit, on good grounds, it is conceived, that there exists a natural tendency in the operations of the animal economy, whether in a state of health or disease, to certain periodical fluctuations, which, under particular circumstances, manifest themselves in a way sufficiently conspicuous to exhibit an obvious revolution in the increase and declension of the morbid actions of the animal system. It was early observed, that there are certain regular periods in the course of many febrile affections, at which prominent changes are wont to occur, preceded generally by a manifest aggravation of the symptoms, and followed or attended by certain evacuations. These evacuations, from their being almost always followed by an obvious abatement in the symptoms, were called critical, and were thought to consist of noxious or febrific mat- ters, thus thrust out of the system by the sanative powers of nature. Fever was supposed to be nothing else than an effort of nature, to prepare and cast out of the system the morbific materials which dis- turbed the regular actions of the animal economy, and that the amend- ment which ensued was the immediate consequence of such elimin- ations of morbific matter. At the present day it is, however, more correctly maintained that these critical discharges are the effects, and not the causes of the melioration which«occurs about the periods at which they take place; and that they are to be viewed, rather as the first manifestations of a favourable change in the condition of the system, than as the immediate causes of such a change. That this is the correct view in relation to the nature of such discharges, there can, indeed, exist no doubt; but this view of the subject does not deprive it of its importance, and directs our attention rather to the periodical exacerbations and inherent tendencies in these mala- dies to terminate their course at one period in preference to another, than merely to the evacuations which are apt to supervene at such times. In no forms of fever, perhaps, are these tendencies to termi- nate at a certain fixed period, more frequently manifested than in inter- mittents. There appears, in these fevers, a tendency to a septenary revolution, which I have often seen verified in the most unequivocal manner. If an ague of the quotidian type be suffered to run on, until it terminates spontaneously, the termination will almost uni- versally occur, if it occur at all, either after the seventh, fourteenth, or twenty-first paroxysms; and I have repeatedly found', that febri- fuge remedies, exhibited immediately after these septenary periods, will arrest it with more certainty, and with much less liability to GENERAL COURSE, &C OF FEVER. 15 relapse,than when employed during any of the intervening inter- missions. From the same inherent tendency, the relapses which are so common in this disease, will, in a vast majority of instances, occur about the septenary periods from the time of the last paroxysm, and most commonly about the eighth or fourteenth, and sometimes for several periods about the twentieth day—(Jackson,* Sprengle.t) Observation has shown, that the crisis of fevers happen almost uni- formly on the odd days, reckoning from the commencement of the malady. According to the observations of Hippocrates, the crises occur in conformity to the tertian type, until the fifth crisis, or the eleventh day of the fever, after which they observe the quartan type, occurring only every fourth day. It must be observed, how- ever, that these evacuations do not occur exclusively on the days just indicated, for they are sometimes, though rarely, found to hap- pen on the intervening days. Galen supposed, that when the cri- sis falls on any other than a critical day, the fever has been diverted from its natural tendency by the accidental occurrence of irritation in some part of the system. Galen divided the critical days into the perfect, the secondary, and the intercurrent. The perfect are those which happen on the seventh, fourteenth, twenty-first, and twenty-eighth days. The secondary, or less perfect, occur on the intermediate day between each perfect or septenary crisis; namely, the fourth, eleventh, eighteenth, twenty-fifth, &c. days. If, for ex- ample, it was observed that a slight deposit in the urine, or a mode- rate flow of sweat took place on the eleventh day, it was regarded as an indication of a more perfect crisis on the fourteenth day. The intercurrent crises occur on the remaining odd days—that is, on the fifth, ninth, thirteenth, &c. Such are the principal points in the doctrine of crisis, as it was taught by the ancients, and more espe- cially by Hippocrates, and his commentator Galen. No one at the present day, however, pretends to have observed the many minute distinctions and phenomena, which are embraced in the ancient doc- trine on this subject; indeed, there are very few who regard it as at all worth any attention; and the profession seem long since to have thrown it into the common mass of error and misconception, which has been formed out of the wrecks of former systems and doctrines. However antiquated it may appear, at the present advanced stage of our science, to profess some faith in the general correctness of this doctrine, 1 cannot, at the risk even of being set down as a cherisher of obsolete and exploded sentiments, divest myself of the conviction, that among much that is erroneous and absurd in this doctrine, there are important and fundamental truths, which ought not to be care- lessly rejected. In order to understand the nature of crisis, every fever must be considered as having a tendency to some one of the principal types * On the diseases of Jamaica. f Handbuch der Pathologie, Band. II. p. 171. 76 GENERAL COURSE, &C OF FEVER. mentioned above. A simple tertian intermittent, may be regarded as the elementary type of fever. In fevers of this type, an exa- cerbation or paroxysm, and a crisis, will occur on every odd day; and if we consider a continued feyer as made up of tertian paroxysms prolonged and running into each other, or as possessing a natural, though countervailed tendency to the elementary or tertian type, there will, in like manner, occur more or less considerable tertian exacerbations, with their accompanying discharges. From what has already been said concerning the manifest septenary movements of intermittents, the tendency of continued fevers to terminate on the fourteenth or twenty-first days, which can scarcely be denied, would seem to be in conformity to an original law of the animal economy, under a state of febrile excitement. The evacuations which usually accompany the crisis of fever are, 1. haemorrhages; 2. a flow of sweat; 3. an increase or changed cha- racter of urine; and 4. diarrhoea. Critical haemorrhages are gene- rally attended with an increased action of the heart and arteries, and often with a manifest determination to, and congestion in the part from which the discharge occurs. They must be regarded as mere manifestations of a previous change in the system, and hence this kind of critical evacuation cannot be substituted bjr an artificial abstraction of blood; since, although blood may be abstracted, the peculiar action of the solids, which constitutes the actual crisis or change to a favourable tendenc)T, cannot be thus produced. Crisis, by haemorrhage, is generally confined to inflammatory fever; or, more correctly speaking, to fevers attended with an increased activ- ity and action of the heart and arteries. Critical haemorrhages most commonly proceed from the nose, and, according to the observations of many of the older writers, are frequently preceded by the dicro- tus pulse, in which two distinct wave-like beats occur during each dyastole of the artery. Immediately before the irruption of the blood the carotids beat strongly, the face becomes flushed, sparks appear before the eyes, the eyes are red and suffused with tears; and, in some instances, frequent sneezing, and a thin watery discharge from the nostrils occurs just before the haemorrhage appears. Critical sanguineous discharges have also been known to occur from the ute- rus, the rectum, and sometimes, though very rarely, from the stomach, and even from external parts. Crisis, by an increased flow of perspiration, is by no means un- common. Catarrhal and rheumatic fevers are more apt to terminate by this mode of crisis, than any other forms of febrile affection. This discharge is not, however, to be regarded as indicative of a favourable change in the malady, unless it be generally diffused over the whole surface, Aid especially, unless it be attended with a tur- bid state of the urine, or a copious sediment in this latter evacua- tion. The surface should, moreover, be soft, and of a natural tem- perature—that is, not cold and clammy. Crisis by urine, independent of perspiration, is a very uncommon GENERAL DIAGNOSIS. 77 mode of termination in febrile complaints. A critical urine derives its favourable character not so much from the mere quantity of the evacuation, as from its appearances and the materials with which it is impregnated or mixed. For inspection, the urine which is evacuated at the termination of a paroxysm, or in the morning, ought to be chosen. In a truly critical urine there may be seen at first a cloud floating in the upper part of the vessel, then a globular body of mucous about the middle, and a sediment at the bottom.* So universal is the concurrence' of a critical urine, and a general moisture of the skin, that these two evacuations may be considered as essentially connected. A critical discharge from the bowels is less common than those I have already mentioned. It occurs most frequently in bilious fevers, and in such febrile affections as are attended with some visceral disease within the abdomen. These discharges do not, however, occur as the others do, in the acme or exacerbations of the fever, but during the periods of remission. They are generally very copious. The signs of an approaching crisis by diarrhoea, are a peculiar trembling of the under lip; stammering speech; a full and wave-like pulse; pain and rumbling noise in the bowels; discharge of wind; a moist tongue; itching in the nose; paucity of urine, &c. (Richter.) CHAPTER IV. ON GENERAL DIAGNOSIS. Nothing so much distinguishes the experienced and truly well- qualified physician from the mere hap-hazard recipe-doctor, and routinist, as the ability to estimate correctly, the import of symp- toms; to trace their various relations with each other, and to deter- mine from them the seat, nature, and extent of maladies. The num- ber of those who are remarkable for accuracy in diagnosis, is always very small; for eminent proficiency in this respect, can be obtained only by persevering observation and study, aided by a minute and comprehensive acquaintance with physiology and pathology. Diagnosis embraces a much wider range of inquiry, than that which is presented by the actual phenomena of diseases. It is not alone from morbid symptoms that the intimate character and tend- * Vogel, Richter, Hufeland. I have frequently noticed these appearances in the urine, evacuated after a paroxysm of intermitting fever; and I am well satis- fied that it is a common occurrence in the urine discharged soon after fevers have commenced to decline. 7S GENERAL DIAGNOSIS. ency of diseases can always be satisfactorily determined. Age, sex, moral and physical temperament, climate, occupation, habit of living, corporeal conformation, previous diseases, hereditary predis- position, and the character of the predisposing and exciting causes, often afford important aid in the formation of a correct diagnosis. In chronic diseases, especially, the light which may be obtained from circumstances of this kind, is frequently of the utmost imporUnce in this respect. The manner in which patients are examined, also, has a direct and important bearing on diagnosis. A confused, desultory, or imme- thodical mode of investigating the symptoms of diseases, and the various circumstances which may have contributed to determine their character, seldom leads to a clear and precise diagnosis. In- deed, the manner in which a physician examines his patients, affords no inconsiderable criterion for judging of his practical qualifications. Method, regularity and deliberation, in this respect, are almost always associated with skill in diagnosis, and consequently in the treatment of diseases. The first objects which strike the attention of the physician, on approaching a patient, are his countenance, attitude, motions, and voice. It is natural, therefore, to commence the examination with these symptoms. In many instances these external conditions of the patient afford very important information as to the nature and seat of maladies; and in no case, perhaps, can they be entirely ne- glected without losing very useful suggestions in relation to the diagnosis. The countenance should be deliberately and closely examined, and its deviations from the healthy aspect and expression noticed. Many diseases are attended with expressions of countenance so pe- culiar and striking, that they may be at once recognised by the ob- servant and experienced physician. The attitude, motions, and external condition of the patient's body, must, also, be particularly noticed. The degree of emaciation—the colour and condition of the skin, and the general physical habit and conformation, should be observed. The various regions of the body should be carefully ex- amined, more especially in diseases of a chronic and obscure cha- racter. In some general maladies, such as scurvy, syphilis, scrofula, &c, the echymoses, glandular indurations, eruptions, blotches, exos- toses, nodes, &c, afford important diagnostic evidence. Old cica- trices, too, merit particular attention; particularly when seated along the neck and in the groins. The former almost always indicates a scrofulous diathesis, whilst the latter afford good grounds for sus- pecting the existence of a syphilitic taint. The existing disease, for which the physician is called to prescribe, may have a very intimate connexion with one or the other of these maladies or constitutional taints; and as patients are apt to neglect giving proper information on this subject, or even seek to conceal the fact of their having been affected with such a disease, these old marks or cicatrices are GENERAL DIAGNOSIS. 79 sometimes of essential service, to a full and satisfactory investigation of the case under examination. Having attended to these external circumstances, the examination of the case must be pursued, by interrogating the patient. The manner in which the examination is conducted, is of great import- ance. A careless, irregular and hurried, or a peevish, fretful and impatient manner of examining, seldom fails to lessen the good will and confidence of the patient, for his medical attendant; whilst a mild, deliberate, earnest and interested deportment, not only gains the patient's confidence and respect, but contributes very materially to a full development and correct understanding of the nature of the malady. The questions should always be proposed in terms perfectly intelligible to the patient; and when there is reason to doubt whether the interrogatory has been correctly apprehended, it should be repeated in different terms. The employment of a pomp- ous and technical phraseology, is more apt to excite the contempt and distrust of intelligent patients, than to draw forth correct and satisfactory responses. It is of considerable consequence, also, to follow a determined and regular order in the questions put to the patient. Without a proper attention to order or method in this respect, important ques- tions are apt to be forgotten, and some which have already been pro- posed and answered, uselessly repeated. Although the interrogato- ries should be sufficiently numerous and varied to obtain a full view of the symptoms and feelings of the patient, and of the circum- stances which may have contributed to the development and modi- fication of the disease, yet trivial and irrelevant questions should be avoided. The following order of inquiry appears to me the most natural and advantageous. 1. Ascertain the age, occupation, and place of residence of the patient. In many instances, indeed, these circum- stances, more especially the last, can have no useful bearing on the diagnosis; but this is by no means always the case; for, in some cases, very important diagnostic and practical suggestions may be obtained from a careful consideration of these facts. 2. Inquire next at what time the disease commenced; whether it came on gra- dually or suddenly; whether the existing symptoms differ from those which attended the disease at an earlier period; whether the progress of the complaint is continuous or paroxysmal, constant or occasional, uniform or attended with exacerbations and remissions; whether, in the course of the disease, new sy Tptoms have super- vened, and former ones disappeared, and whether the permanent symptoms have increased much in violence since the commencement of the complaint. Correct information in relation to these circum- stances is often indispensable to a satisfactory diagnosis. " In many instances, indeed, the succession anchronic form of the disease. In chronic gastritis, and enteritis, the tongue almost invariably exhibits a dark red appearance. In some instances, this redness is attended with a rough or granulated surface, and in others it presents a smooth or glossy appearance; sometimes the whole surface of the tongue exhibits this red and rough or glossy appearance. This is generally the case when the inflammation is seated in the stomach. In many instances, however, these appear- ances are confined to the tip and margins of the tongue, more espe- cially when the inflammatory irritation is located in the mucous membrane of the colon. In fevers depending"on acute inflammation, not seated in the mu- cous membrane of the alimentary canal, the tongue seldom exhibits any prominent deviations from its natural state. Thus in fevers from wounds, from regular gout, and from external phlegmanous inflammation, the tongue generally varies from its healthy condition, only by being covered with a thick white fur, and by unnatural dryness.,—(Hall.) In the commencement of typhus fever, the tongue is coated with a white fur, as in common synochus fever; but the white tongue of typhus, differs from that of simple acute fever, in being covered with a thick layer of transparent, tenacious slime, which in the progress of the disease becomes dry, brown, and finally nearly black. The appearance of the tongue affords a good distin- guishing sign between tubercular phthisis pulmonalis, and hectic fever with cough from hepatic or gastric disease. In genuine pul- $ monary consumption the tongue very generally retains nearly its natural appearance; whereas in affections of the stomach and liver simulating phthisis pulmonalis, the tongue is always more or less coated with a brown fur, accompanied usually with a depraved taste. GENERAL DIAGNOSIS. 93 In the early stage of chlorosis the tongue presents a pale and tumid appearance, with enlarged and prominent papillae. As the disease advances the tongue becomes more and more pallid, clean, and smooth, and finally acquires a peculiar flabby and semi-transpa- rent appearance. The gums and prolabia are very pale and* exan- geous, and generally somewhat swollen. Hall gives the following description of the morbid appearances of the tongue in dyspepsia. " In acute dyspepsia, the tongue is in general loaded, the mouth clammy, the taste bitter or nauseous, the breath fetid, whilst the sur- face of the face is generally oily. In some severe cases the coat on the tongue is very thick, and eventually peals off, leaving its surface smooth, red, and tender, attended with an oedematous appearance of its substance. In very protracted and severe cases of dyspepsia the tongue is apt to become clean, with universal enlargement of the papillae over the surface as in the beginning of chlorosis; or its sur- face is formed into lobules resembling in form those of the base of the cerebellum. In cases attended with chronic inflammation of the mucous membrane of the stomach, the surface of $ie tongue becomes red, smooth, and glazed." The appearance of the tongue in chlorosis does not differ materially from that which it presents in chronic dyspepsia, except that in the former disease it is pale instead of red, and indicates, in addition to gastric derangement, a defect in the pro- cess of sanguefication.—(Hall). A contracted and pointed tongue, is a very common attendant on inflammatory affections of the brain and its meninges. This state of the tongue is often to be observed in very severe cases of typhus; and when it does occur we almost invariably find it associated with other indications of cerebral inflammation,—such as red and promi- nent eyes, constant delirium, flushed cheeks, &c. In fevers attend- ed with stupor or general torpor, depending on congestion, the tongue instead of being contracted and pointed presents a dilated and flabby appearance. This relaxed and dilated state of the tongue is seldom accompanied by delirium; but instead of this, there is usually a general diminution of sensibility and irritability, as well as of muscular power and the temperature of the surface. Dr. Miner mentions this appearance of the tongue as one of the most constant symptoms of typhus syncopalis. A tongue covered with yellow, or yellowish brown fur, attended with a bitter taste, indicates prominent derangement of the biliary organs. A tremulous tongue, is, in general, one of the first symp- toms of the passage of the synochus fever into a typhous or low state. In the early stage of scarlatina, a number of florid papillae pro- trude through the white coat on the surface of the tongue; and Bate- man states, that this appearance will always enable us to distinguish it from measles. In chronic hepatitis, the gums have a peculiar firm, smooth, or glossy appearance, whereas in chronic dyspepsia, they usually present a soft or spongy condition. 94 GENERAL DIAGNOSIS. The next class of symptoms to be considered, are those manifest- ed by the nervous system. The most common, and generally the earliest symptom of deranged function of the brain, is disturbed sleep. In the diseases of children, an unusual drowsiness, especially when* attended with a disordered state of the alimentary canal and febrile'irritation, is often one of the first symptoms to awaken alarm and suspicion of probable disease within the head. Under whatever circumstances profound morbid sleep or coma may occur, it always denotes cerebral oppression from congestion or effusion, or some other cause capable of compressing this organ. When, therefore, in the course of diseases attended with symptoms of cerebral irritation or inflammation, somnolency supervenes, we may conclude that great congestion, or effusion, or disorganization of the cerebral structure, has taken place. Wakefulness is indicative of great cerebral irritation or exhaus- tion. It is particularly apt to occur from sympathetic excitement of the brain, depending on intestinal irritation, and exhaustion from loss of blood. When morbid wakefulness depends on these causes, it is almost invariably attended with great restlessness or jactitation, a distressing feeling of anxiety in the region of the heart, and a pale and contracted countenance. Sudden starting during sleep js gene- rally connected with intestinal irritation from indigestion or worms (Hall.) Children whose bowels are loaded with sordes or worms are particularly apt to start in sleep, " and this symptom is one of the most certain diagnostic signs of such a condition of the aliment- ary canal." Similar hurried wakenings occur in organic affections of the heart, and in hydropericardium, and frequently, also, in hydro- thorax; but in these complaints, the starts from sleep are almost al- ways attended with a distressing sense of suffocation, or impending dissolution, great agitation and alarm. Acuteness of hearing and sight occur in the incipient stage of cerebral inflammation; but they are equally, and often more strik- ingly presented in sympathetic irritation of the brain from intestinal irritation, accompanied with exhaustion (Hall.) As a general ob- servation, however, it may be said that when the senses of sight and hearing are morbidly acute, or when there is intolerance of light and sound, the brain is in a state of irritation, whether sympathetic or idiopathic. Obtuseness of hearing is a common symptom in the advanced stages of typhoid fevers, and indicates a considerable de- gree of sanguineous engorgement, but not inflammation of the brain. Strabismus, and seeing objects double, always denote very consi- derable cerebral disturbance. These symptoms arise from sanguine- ous or serous effusion into, or upon the surface of the brain, and from disorganization of a portion of the structure. Torpor or defect in the sense of touch, if general or confined to one side of the body, ■ indicates an oppressed state of the brain, and may be both the pre- W cursor or consequence of apoplexy. When torpor of feeling is con- J fined to one extremity, or only to a part of an extremity, We may 1 GENERAL DIAGNOSIS. 95 infer that the nervous communication between the affected part and the censorium commune has been partially interrupted, by compres- sion of the principal nerve leading to the part, or that the nervous extremities of the part have become diseased and incapable of trans- mitting the nervous power. Morbid sensations are among the most common phenomena of diseases. In many affections, indeed, there are peculiar and cha- racteristic modifications of sensibility, which it is of importance to notice in a diagnostic point of view. In strumous disease of the mesentery, an unusual sensibility to cold constitutes a peculiar and very early symptom. " In this disease, the patient is greatly sensi- ble to cold and to the least draught of air, and in cold weather espe- cially, constantly draws near or hangs over the fire, until the hands and legs assume a brown colour from the influence of the heat." Pain may depend on inflammation, on spasm, or on nervous irri- tation. Each of these kinds of pain has a peculiar character by which it may in general be readily distinguished. The pain of in- flammation is attended with great tenderness or soreness of the affected part—is increased by pressure,—generally continuous, and always attended with more or less of febrile irritation. Spasmodic pain, on the contrary, is intermitting—is neither throbbing nor burn- ing, like that of inflammation, nor is it attended with redness, swelling, augmented heat, or febrile excitement. Pressure, which always in- creases the pain of inflammation, generally mitigates spasmodic pains. Neuralgic pain differs from inflammatory and spasmodic pain, by occurring in transient and extremely violent paroxysms. It darts with the rapidity of lightning along the ramifications of the affected nerve. It is not attended by swelling or increased heat, unless some degree of inflammation be associated with it; and the slightest agita- tion or touch is apt to renew its excruciating paroxysms. It is a fact demonstrated by daily observation, that the character of inflammatory pain is peculiarly modified by the nature of the struc- ture in which the inflammation resides. This circumstance neces- sarily arises from the physiological fact, that each structure of the animal system is.endowed with a peculiar modification of the vital properties. From this variety in the general character of inflamma- tory pain, according to the structure in which it resides, we fre- quently obtain important diagnostic indications. In the mucous membranes, inflammation is attended with a burning or stinging pain, and is seldom very violent: in the serous membranes the pain is lancinating, and generally extremely acute; in the fibrous tissues, it is dull, aching and gnawing; in the nerves, rapid, darting, remitting and excruciatingly severe; and in the parenchymalous and cellular structures, it is dull,throbbing and heavy. ' Thus the pain experienced from inflammation of the pleura, is acute, piercing, and generally ex- tremely severe; whilst that from inflammation of the substance of the lungs is dull, pressing, and generally inconsiderable in violence. The pain attending inflammation of the mucous membrane of the sto- 96, GENERAL DIAGNOSIS. mach is of a burning, gnawing, or stinging character; that of the iver is acute, throbbing, and generally accompanied with a sense of fulness and tension in the right hypochondrium and epigastrium. 1 he cha- racter of the pain may, moreover, assist us in determining in what portion of this organ the inflammation is principally seated. When the substance of the liver is the principal or exclusive seat of the in- flammation, the pain is seldom very acute or violent—being obtuse, heavy, and heating. When the convex surface of this organ is af- fected, the pain is usually extremely severe, darts upwards towards the left or right shoulder, and is always much increased by external pressure, deep inspiration, cough, and motion. In cases where the concave surface is the seat of the inflammation, the pain is, in gene- ral, dull, accompanied with much anxiety in the epigastrium, nausea, and often, vomiting. Cases of this kind, frequently resemble gas- tritis; but may be distinguished from this affection by the pain, dis- tress and vomiting not being increased by taking warm liquids into the stomach. In many instances, the painful sensation is referred to a different and often 'remote part, from that in which the primary irritation or affection is seated. Irritation in the neck of the bladder, frequently gives rise to pain in the glans penis; inflammation of the liver often causes pain in the left, and sometimes right shoulder; and severe and protracted pain in the knee and legs, is generally among the first painful sensations attending hip disease. In many cases, indeed, pain in the knee is felt for a considerable time before any unpleasant sensations are experienced or complained of in the hip; and I have not unfrequently known various applications made to the knees of children for the relief of pain in that part, which was subsequently found to be merely symptomatic of scrofulous disease of the hip. Inattention to these and similar facts, has often led to very useless and painful applications, and placed the physician under the morti- fying, and indeed, justifiable imputation of ignorance or culpable carelessness. The next class of symptoms to be considered, are those manifested by the morbid conditions of the alimentary canal. From the nature and appearancee of the alvine evacuations, we may often derive im- portant diagnostic information. The functional derangements of the liver are, in general, readily distinguished by the character of these evacuations. Ash, or clay-coloured faeces, indicate either deficient se- cretion of bile, or obstruction to its regular flow into the intestines. This condition of the biliary organs is almost always attended with increased irritability of the stomach. When the alvine discharges are liquid, and of a bright green colour, as is frequently the case in infants, the existence of much acid in the bowels may be confidently inferred. Bile, as it comes from the liver, never possesses such a colour. It is only by being mixed with acid in the intestines, that it acquires this appearance. However dark and vitiated the bile may be before it is discharged into the bowels, it will always communi- GENERAL DIAGNOSIS. 97 cate a yellow colour to water. It becomes green in the intestines by the action of the acid it meets there. According to. the observa- tions of Doctor Cheyne, the appearances of the stools afford a good diagnostic sign between infantile remittent fever, and hydrocephalus. In the former disease, the alvine discharges are, generally, dark- brown or mud-like, and extremely fetid. In hydrocephalus, the stools are usually gelatinous, dark green, sometimes black, like tar, and of a peculiar sickly smell. Watery and reddish stools, contain- ing small flakes of mucus, resembling the washings of flesh, always indicate a high degree of inflammatory irritation of the mucous mem- brane of the small intestines. The diagnosis of diseases is also much aided by an attention to the morbid conditions of the respiratory organs. In general, the greater the velocity and momentum of the blood, the more rapid is the respiration. In acute diseases, attended with a frequent and full pulse, breathing is always accelerated. In affections of the head, at- tended with sanguineous congestion in the brain, respiration is gene- rally more or less irregular, unequal, and suspicious. When the congestion, and consequent cerebral compression, is so great as to produce partial insensibility, the breathing becomes slow, irregular, and sterterous. Whatever obstructs the functions of the brain, or interrupts the nervous communication between it and the respiratory apparatus, impedes or destroys the function of respiration; and the slowness and irregularity of the respiratory acts will be in propor- tion to the degree in which the functions of the brain are oppressed. In pneumonia, breathing is sometimes performed by the action of the diaphragm alone, without any perceptible elevation and depres- sion of the ribs of the affected side. In abdominal inflammation, with acute pain, on the contrary, respiration is performed, almost ex- clusively by the action of intercostal muscles, the alternate rising and falling of the abdomen, so conspicuous in thoracic inflammation, being almost entirely absent. "This peculiarity of breathing," says Dr. Hall, "may be distinctly observed by looking on the chest and drawing the bed-clothes tight over the abdomen: the respiration has sometimes the appearance of heaving of the chest; every movement of the diaphragm is cautiously avoided, on account of the motion which its action communicates to the abdominal viscera. The dia- phragm and abdomen begin to move, as the pain diminishes, whether from mitigation of the disease, from sinking, or from gangrene." In inflammation of the substance of the lungs, or of the mucous membrane of the ultimate bronchial tubes, respiration is performed with great difficulty, and in violent cases, with distressing anxiety and labour. " The shoulders are elevated, and the lower part of the stern- um is drawn back, during each act of inspiration, whilst the abdo- men is at the same time suddenly protruded, and the upper part of the chest raised." In the diseases of children, the manner in which re- spiration is performed often throws important light on the character of the disease. When, with more or less cough, the inspirations are Vol. I.—13. 98 GENERAL DIAGNOSIS. short and catching, more especially when the countenance, at each inspiration, exhibits an expression of pain or suffering, the existence of pectoral inflammation may be confidently inferred. If the coun- tenance is pale, and the breathing wheezing and laborious, the inflam- mation is probably seated in the mucous membrane of the bronchia. Laborious and anxious breathing on muscular exertion or strong mental excitement, particularly from walking up hill, or ascending stairs, is strongly indicative of organic disease of the heart. The dyspnoea of hydrothorax differs from that of organic cardiac disease, in being more liable to recur in violent paroxysms from the causes just mentioned in the latter than in the former affection. In hydro- thorax, too, the dyspnoea, thus excited, comes on gradually, whilst in organic disease of the heart the paroxysm of suffocative breathing re- curs with sudden violence. Asthma is attended with a peculiar mode of dyspnoea. The act of inspiration consists of a quick and imper- fect dilatation of the thorax, but expiration is much more protracted, laboured and wheezing. "When the disease is violent, every muscle subservient to this function is brought into strong exertion, with the exception of the intercostals, which, although excited to strong efforts, are incapable of that degree of action which is necessary for the due expansion of the chest. What, however, particularly characterizes the dyspnoea of asthma, is the wheezing during expiration." When the breathing is hurried, panting, sighing, and the lun^s are but partially filled during inspiration, there is probably much de- bility accompanied or depending on nervous intestinal irritation. This state of the system and of the respiratory organs, is generally attended with great restlessness, jactitation, and inability to sleep. Having described some of the more remarkable diagnostic phe- nomena, in relation to respiration, it remains for me to consider the diagnostic indications derived from the character and attending circumstances of coughing. With regard to the phenomena of cough, therefore, we may notice the following general diagnostic circumstances: Patients affected with inflammation of the pleura, lungs, or peritoneum, always repress the cough as much as possible, in order to obviate the great increase of pain which free coughing invariably produces in these affections. When, therefore, the patient is observed to make great efforts to stifle or suppress the acts of coughing, the existence of local inflam- mation may be confidently inferred. The seat of the inflammation will be pointed out by the other accompanying symptoms. The cough attending acute inflammation of the mucous membrane of the bronchia has a much duller sound, and is attended with much more mucous rattling in the chest than that which results from acute inflammation of the pleura This remark applies particularly to the SS/r^T? ti feCtl°nS; *?rin the advanced stage of the latter malady the cough is generally as dull and rattling at in bron- chitis. Cough depending on gastric or intestinal irritation is gene- rally attended with a peculiar hollow sound: this kind of' cpufhX GENERAL DIAGNOSIS. 99 frequently met with in children labouring under verminous irritation. The character of the cough will, in general, afford considerable aid in distinguishing phthisis laryngea, from phthisis pulmonalis; or that form of consumption which arises from ulceration in the larynx, from true pulmonary consumption. In the former the cough comes on in violent and spasmodic paroxysms, particularly in the morning on rising from bed; whilst in the latter form of the disease, the cough is, usually, much less sudden and violent in attacks, and is, besides, destitute of the spasmodic or convulsive character of the former. In the laryngeal variety of the disease, the cough has a deep hollow sound, not unlike that which is produced by verminous irritation of the bowels, whereas, in pulmonary phthisis, it always has a "flat- tened and lacerating sound." In the former of these maladies, vio- lent fits of coughing are excited by the patients passing from a warm into a cold air, by inhaling smoke or the dust raised by sweeping, or any irritating fumes, and the same effect is frequently produced by swallowing food. In pulmonary phthisis, coughing is very rarely excited by these causes, and when they do produce this effect, the cough is usually slight and of very short duration. The character and appearance of the matter expectorated, afford important diagnostic indications. In peripneumonia, the tenacity of the matter expectorated is so great, that we may reverse the ves- sel which contains it, and retain it in tine position for some time, without detaching it from its sides. iRiennec regards this kind of sputa, as pathognomic of this affection, "since it is the only symptom which is found exclusively in this form of pulmonic inflammation." These sputa are somewhat diaphanous and of slightly yellow or greenish colour. In acute bronchitis the expectoration is much less tenacious in its consistence, and is generally quite transparent, resem- bling the white of eggs. When the fluid expectorated has a dark appearance, like dissolved blood, and possesses a very fetid smell, we may infer that some portion of the diseased lung is in a gan- grenous condition. In chronic bronchitis, particularly in those cases which result from portussis, the matter expectorated often presents a white, cream-like appearance, bearing considerable resemblance to the whitish friable matter which is sometimes brought up in small quantities in the latter stage of tubercular phthisis. This white matter, in the latter disease consists of the softened substance com- posing the tubercles. Mucous membranes, under a high degree of irritation, often secrete a fluid, which bears a strong resemblance to genuine pus; but which in its composition and properties, is never- theless, strictly a mucus. Various tests have been recommended for distinguishing puruloid secretions of this character, from genuine pus, and a correct decision on this point, is of much importance in forming a satisfactory diagnosis; for when the matter expectorated is found to be pus, there can be no doubt, that the structure from which it proceeds is in a state of active inflammation or ulceration. If, oa*«ffie contrary, it be found to possess the character of mucus, 100 urrNERAL DIAGNOSIS. we may infer, that neither an active state of inflammation nor^ulcer- ation exists in the diseased organ, but only a high degree of imita- tion or sub-inflammatory excitement. The specific gravity ot pus is considerably greater than that of mucus-the former sinks in water, the latter floats on the surface. This is the usual test, but cannot always be relied on; for although we may safely pronounce the matter expectorated to be pus, when it sinks quickly to the bot- tom of the vessel, yet we cannot, with entire assurance, inter that it is mucus when it remains floating on or near the top of the water; lor a considerable portion of pus is often so intimately mixed with bronchial mucus, as to give it nearly a uniform appearance, and cause the sputa to swim on the surface. The following tests haye been proposed, and I think, entitled to confidence.—The muriate of ammo- nia coagulates pus; but on mucus no such effect is produced by it. Heat coagulates mucus, but not pus. Water added to the solutions of pus in sulphuric acid, and in a solution of caustic potash separately, produces, in each, a copious precipitate. Mucus treated in the same way, does not exhibit the same effect. Dr. Young mentions the following test: A small portion of pus put between two glasses, will, when held near the eye, and looked through at a distant candle, exhibit an iridescent spectrum, of which the candle is the centre. Mucus does not present this phenomenon The morbid conditiorisfcdithe external surface of the body should always be carefully observer* In examining diseases, particular at- tention should be paid to the temperature, the colour, the state of dryness or moisture, the fullness or constriction, and the roughness or smoothness of the skin. The existence of oedema, or of emacia- tion, are, moreover, important diagnostic circumstances. A yellow- ish or icteric hue of the skin, and especially of the tunica albuginea, are well known indications of derangement of the biliary organs. In the various forms of disease produced by marsh miasmata, this symptom is rarely absent. This appearance of the skin, says Mr. Hall, must not be confounded with the sallow hue which occurs in chloipsis, cancer, and some other organic affections. " Sallowness is notrnecessarily accompanied by a yellow hue of the albuginea; but the icteric appearance of the skin is always associated with a similar tinge of the eyes. When, therefore, the albuginea is free from this yellowish hue, we may infer that the biliary organs are not particularly disordered, however sallow the general surface may be. When a decided icteric or jaundiced hue of the skin, is asso- ciated with constant and obstinate torpor of the cutaneous exhalents, or dryness of the surface, we may infer that the biliary derange- ment, upon which these phenomena depend, consists of chronic in- flammation and induration of the liver; and this diagnosis may be regarded as still more certain, if, at the same time, the gums have a peculiar and unnatural firmness. A purple or bluish colour of the skin, when not the immediate consequence of cold, indicates defi- cient decarbonization of the blood in the lungs. This appearance GENERAL DIAGNOSIS. 101 occurs, in a striking manner, in the Asiatic cholera. When this livid hue is confined to some particular part of the body, it denotes great venous congestion in the part. Thus a livid colour of the face indicates great engorgement of the blood-vessels of the head, and is almost universally connected, or rather dependent on obstructed cir- culation through the lungs, and attended with an imperfect perform- ance of the respiratory functions. A pale semi-transparent appearance of the surface, particularly of the prolabia and face, occurs after profuse haemorrhage, or from what- ever greatly exhausts the system or impedes the process of sangui- fication. This appearance of the skin is always accompanied by great languor and debility, and depends, generally, on a morbid ex- cess of the serous portion of the blood. This state of the system is almost invariably attended with more or less of anasarcous effusion. A pale and cachectic appearance of the face, attended with a leaden hue of the prolabia and a puffy swelling under the eyes, is fre- quently noticed in organic affections of the heart. A cold state of the surface of the body, attended with a sensation of heat.in the internal parts, indicates great sanguineous congestions of the viscera. The heat is sometimes very unequally distributed throughout the various parts of the body, and it may be laid down as a general rule, that in whatever part the heat is preternattwally elevated, there is an unusual determination of blood to that-part. Thus in hydroce- phalus, the head is almost always considerably warmer than any other part of the body; and in dysentery and peritonitis fhe abdo- men is preternaturally hot to the touch, whilst the extremities in the latter stage of the disease are unusually cool (Hall). In organic affections of the heart, the hands, nose and cheeks are very apt to become preternaturally cold, whilst the heat within the rectum and under the tongue is generally considerably higher than natural (Fare.) A pungent, stinging heat of the surface, or the calor mordax, as it is technically called, indicates a high grade of malignity or a tendency * to putrescency in fevers. This pungent heat differs very distinctly from the burning heat which occurs in synochial or inflammatory lever. By laying the hand on the skin of a patient labouring under inflammatory fever, the sensation of heat is at first very great, but on suffering the hand to remain for a short time, the sensation of heat gradually diminishes, until it seems to the touch but little, if in any degree, above the natural temperature of the body. In typhus gravior, on the contrary, the heat (calor mordax) becomes more and more pungent and severe, and the biting or acrid sensation of heat remains in the hand, even after it is removed from the patient's body. The appearances and character of the urine also, often afford valu- able diagnostic indications. In inflammatory affections it is gene- rally very red and small in quantity; in nervous diseases, more espe- cially in hysterical affections, this secretion is usually copious and limpid, or but slightly coloured. In diseases of the biliary organs, 102 GENERAL DIAGNOSIS. the urine is almost invariably conspicuously tinged with bile. To distinguish urine coloured with bilious matter from the highly colour- ed urine of inflammatory fevers, a small strip of white linen or paper should be immersed in it. If the urine contains bile, the linen or paper will receive a very distinct yellow stain, which will remain when dried. If it be free from -bilious matter no such tinge will be communicated. Much has of late years been said concerning the connexion between a serous or coagulable condition of the urine (in hydropic affections), and a phlogistic or inflammatory state of the system. Drs. Blackall, Wells, and Ayre, have investigated this subject with minute attention. It has been satisfactorily ascertained by these and other pathologists, that those cases of dropsy which are attended with an obvious phlogistic diathesis, and especially such as arise from the influence of general causes, the urine, with scarcely an exception, contains a large quantity of coagulable serum. The quantity of serum mixed with the urine may, therefore, be regarded as a pretty correct index of the degree of general inflammatory.ex- citement attending the disease. Serous urine may be. regardeijas a sort of pyrexometer in hydropic affections, which, though not uni- versally to be relied on, is yet sufficiently constant to entitle it to the attention of the practitioner. I am satisfied, from considerable attention to this subject, that in almost every instance where there is coagulable serum in the urine of dropsical patients, the general condition\)f the system* will be found manifestly phlogistic. The mode of testing the urine, for this purpose, is to expose a portion of ■*! it in a spoon to the heat of a lamp. When, in hydropic affections, the urine is high-coloured, and on cooling becomes muddy, or de- posits a red or reddish sediment, we may infer with great proba- bility that the liver is in a state of organic disease (Cruikshank). 103 OF T*fE ACUTE DISEASES OF THE SANGUIFEROUS ^ SYSTEM. DEPWfl —•»*$ @ ©4««— OF_GENERAL^ClITATIVE DISEASES* OF THE BLOOD-VESSELS INDEPENDENT OF LOCAL INFLAMMATION. V CHAPTER V. oAnTERMITTING FEVER. fTERliiTTiNG fevers occur under the three primary types men- id in a preceding chapter, and occasionally under the various Plications which these types are liable to assume. According le type which they assume, therefore, they are divided into quo- tians, tertians, quartans, quintans, fyc. The fit or paroxysm of an intermitting fever consists of three distinct periods, all of which are characterized by a series of pecu- liar phenomena, each succeeding period being the immediate con- sequence of the one which precedes it The symp'to'ms which characterize the forming stage of an inter- mittent paroxysm, do not dijffel*ir*br5i ^hose which usually precede the development of other wrhs of fever.**' * A sense of great lassi- tude, frequent yawning and stretching, a feeling of uncomfortable weariness of the whole body, and slight aching pains in the loins and extremities, constitute the first manifestations of the approach of an intermittent fever. Cold stage.—After the foregoing symptoms have continued for an indefinite time, the patient begins to experience slight and tran- sient sensations of cold along the back; attended often with an irre- sistible disposition to yawn and change the position of the extremi- ties; the fingers and feet lose their natural temperature, and feel slightly benumbed; the patient becomes restless, ancj.soon tired of the same position; his ideas pass with unusual rapidity through his mind; he is incapable of fixing his attention upon any particular ob- ject, and generally manifests an unusual irritability of mind, or ill temper, or a taciturn moroseness. The sensation of chilliness, with more or less rapidity, extends itself from the extremities over the whole body; the skin becomes universally pale, contracted, and rough; the pulse loses its activity and size, becoming small, con- tracted, frequent, and firm. Wh?n the sense of chilliness has passed 104 INTERMITTING FEVER. in ^1 from the extremities to the body, a slight trembling of the muscles begins, generally, at first, in the jaws, and extending thence quickly over the whole frame. This trembling is sometimes so severe as to agitate the patient as if he were in a paroxysm of convulsions, and sometimes exhausts him so much as to leave him scarcely able to move his limbs after their subsidence. These tremors are teehni cally called rigors. During the chills the sensibility of the sur face is benumbed, and the whole body becomf! diminished ir volume, so that rings which were previously tight drop from the fingers. The feeling of cold is not confined to|the surface,Jaut ap- pears in violent cases to penetrate even to the bones, and toj^ijpde, the whole system, "and is accompanied with an indescribabjj sensei W of universal pain and of fatigue."* The breathing also is rftffed,' W anxious, and oppressed, and frequently atteq/ed with a shdjkclry cough, deep sighing, and a sense of weighfrand tightness irMhe chest. Along with these symptoms there ofcuFs4feually much If- t jection and confusion of the mind, and, in soAe instances, a slight de^ gree of delirium. In very debilitated persons a violent fit of nafl often induces a complete state of stupor or coma, more «spedB when feebleness of body is attended with general plethora. In mmy instances, frequent and distressing vomiting occurs, particularly aUut the period of its subsidence, and the ejections are generally bilws, though occasionally ropy, transparent, and insipid. The thirs^l always urgent in this stage, and the mouth and fauces are dry and clammy. The urine is clear, colourless, without sediment, and often copious. Generally, the chills are universally diffused over the body; but in some cases they occur partially, remaining confined to one or more parts of the body; and instances have been recorded in which a single extremity only was,a$ect*i" with the chills. In some cases of intermitting fever, the cold stage is attended with but a very slight sensation of chilliness creeping along the back and over the extremi- ties; and I have known this stage to commence with violent vomit- ing, and to terminate speedily in stupor and partial insensibility. The duration of the cold stage is very various, ranging from a few minutes to four or five hours. Sooner or later, however, the chills begin to abate; transient flushes of heat pass over the face and body; the chilliness now recedes rapidly, and the heat encroaches pari passu, until it has obtained an entire ascendency. At this time the nausea and vomiting are usually most severe—both of which often continue until the hot stage is completely developed. The hot stage is characterised by a full and flushed countenance; an intensely hot and dry state of the surface of the body; o-reat thirst and dryness of the mouth; great acuteness of the sensorial powers; a full, strong, and frequent pulse; a more free and regular respira- tion than in the preceding stage, though still more oppressed and hurried than natural; great pain in the forehead; pain in the back * Macculloch, on Intermittent and Remittent Fever, &c. INTERMITTING FEVER. 105 and extremities; sometimes slight delirium just before the commence ment of the succeeding stage; a scanty and deep-coloured urine with- out sediment. This stage is as various in its duration in different cases, as the preceding one. It continues, however, almost always much longer than the cold stage. The temperature of the skin is always very considerably augmented. Fordyce observed it as high as 105° of Fahrenheit. This stage terminates in the last, or,— The sweating stage.—When the perspiration begins to appear, an obvious abatement of all the febrile symptoms occurs. The sweat appears at first about the head and breast, and thence gradu- ally extends over the whole surface of the body. On the appear- ance of this evacuation, the pulse loses its hardness and frequency, but still retains its fulness. The breathing at the same time be- comes free and natural; the febrile heat subsides rapidly; and the urine, though still very high-coloured, deposits a lateritious or pale red sediment. This*»gradual melioration of the febrile symptoms continues under the free flow of the perspiration, until the paroxysm terminates in a state of perfect convalescence or apyrexia. • j^fhe apyrexia, or intermission, though entirely free from febrile phenomena, cannot, however, be regarded as a state of health; for, during this interval, the patient usually feels some degree of lan- guor; becomes easily fatigued; complains often of a want of appe- tite, and an indisposition to bodily or mental exertion. He pos- sesses, moreover, an unusual degree of sensibility to the impressions of cold air; and his countenance exhibits a pale and sickly aspect. In some, though comparatively few instances, the appetite is good, and the patient experiences no feelings of indisposition whatever during the intermission. The mo*e conspicuous the symptoms of imperfect health are during the intermissions, the more difficult, in general, will it be to prevent its recurrence; orj the more readily- will it relapse after it has been suspended. Intermittents of every type are subject to certain prominent modifications in relation to their general character, which, as,they have important practical bearings, deserve particular attention. We meet with intermittents, for instance, which are attended with une- quivocal manifestations of an inflammatory character; others occur in which symptoms of great internal venous congestions are equally conspicuous; a third variety of intermittents will exhi- bit strong symptoms of biliary and gastric irritation; and a fourth variety will be characterized by phenomena indicative of a more or less malignant character. According to these circumstances, intermittents may be divided into the four following varieties, viz. 1, the injlammatory; 2, the congestive; 3, the gastric; and 4, the malignant intermittents. 1. Inflammatory intermittents occur most frequently during winter and in spring. Quotidians are more apt to assume this cha- racter than tertians; and tertians more apt than quartans, (Richter.) In young, robust, and plethoric subjects, vernal quotidians are espe- Vol. I.—14 106 INTERMITTING FEVER. cially prone to manifest inflammatory symptoms. Intermittents of this character, generally begin with strong rigors. In the hot stage, the temperature of the surface is very intense, and the pulse is pecu- liarly strong, hard, and full. The most characteristic marks of in- flammatory intermittent, occur, however, during the intermission. However profuse the perspiration in the last stage, the apyrexia does not become complete. The pulse remains quick, somewhat tense and accelerated; the thirst is still considerable, and the skin dry and warmer than natural; the whole system is irritable; the temper is fretful or discontented; slight headach is experienced; and tran- sient pains are often felt in the extremities and the back. In many instances a short and dry cough occurs, with some oppression in the chest, or other pectoral affections. Richter observes, that inflam- matory intermittents are very rarely attended with symptoms of gastric disturbance from vitiated secretions, bile, &c. The intermis- sions in agues of this kind are usually short. (Richter.) 2. Congestive intermittents occur seldom. They happen ge- nerally in persons of exhausted and debilitated habits; and in such as are of an irritable and nervous temperament, connected with habitfcl ■ or accidental debility. They are characterized by a very protracted cold stage, deep-seated pain in the head, vertigo, fainting, a sense of weight or oppression in the breast, coma, a small and weak pulse; the hot stage coming on very slowly, and developing itself very im- perfectly, so that instead of hot skin, flushed countenance, and a full and vigorous pulse, the system continues to be oppressed, the skin scarcely warm, the countenance pale and contracted, the breathing confined and anxious, and the pulse frequent, small and tense, with an internal sensation of heat. 3. Gastric intermittents are characterized by prominent symp- toms of gastric and intestinal irritation, redundancy of biliary secre- tion, and other saburral matters lodged in the alimentary canal. The ordinary intermittents of the temperate climates, occurring in autumn, are usually of this kind. Intermittents of this modification are attended with a foul and bitter tongue; much nausea and bilious vomiting; great pain in the forehead; diarrhoea, an icteric hue of the skin and albuginea; urine loaded wiih bilious matter; thirst for acid drinks, and sensation of weight or fulness in the right hypochon- drium. Intermittents of this kind are apt to produce visceral disor- ders, more especially indurations of the spleen and liver; and finally, a cachectic condition of the system which it is often extremely dif- ficult to remove. (Richter.) 4. Malignant intermittents are of frequent occurrence in hot climates, and are always of the most dangerous character. They are characterized by a very copious and fetid perspiration in the third stage, together with colliquative haemorrhages from various parts of the body, sometimes petechia, and other marks of malignity. They run their course with great rapidity, death usually taking place in the third paroxysm. (Alibert.) INTERMITTING FEVER. 107 Irregular and anomalous intermittents. Intermittents do not, however, always pursue the regular course that has just been de- scribed. In some instances, anomalies of a remarkable character occur, both in relation to the phenomena, and the succession of the stages of the disease.- I have known a case, in which the two first paroxysms occurred, in a perfectly regular manner; but after employ- ing arsenic, unsuccessfully, during the second and third intermissions, the paroxysms returned without a cold stage, the patient experi- encing, instead of it, a peculiar feeling of numbness on the top of the head, with great dulness of hearing, for about forty or fifty minutes-before the supervention of the hot stage. There are in- stances on record, of the inversion of the natural order of the cold, hot, and sweating stages; several distinct instances of which oc- curred under my observation in the fall of 1828. Cases have been noticed, in which the perspiration, in the third stage, was subsituted by diarrhoea; and CJeghorn states, that he saw tertians, which ter- minated by an increased flow of urine, with scarcely any sweat. In infants, the paroxysms of intermitting fever are sometimes ushered in by convulsions; but the convulsions are most apt to occur at the commencement of the hot stage. Indeed, the cold stage of very young children is seldom marked by distinct rigors. A pale and shrunken countenance, with an obvious reduction of the tem- perature of the surface, yawning, and stretching, usually manifest the presence of this stage in infants. There are certain affections, not of unfrequent occurrence, which, from their strict periodicity, as well as from their apparent origina- tion from the same causes that give rise to intermittents, are termed masked agues, febres intermittentes larvatse. Thus, neuralgia, in various parts of the body, sciatica, rheumatism of the eye, haemi- crania, toothach, cramp in the stomach, dysentery, cholera, hiccough, mania, and acute pains in other parts of the body,* have been known to recur in a manner strictly periodical, and to have yielded readily to the same remedies which are found to arrest the course of an ague. These affections, when thus perfectly periodical, generally manifest their alliance to intermitting fever, by being almost always preceded by a very slight sensation of chilliness, and by being attend- ed with a moist skin and a turbid urine at the termination of the pa- roxysm. (Richter.) Intermittents are sometimes complicated with other affections, such as dysentery, cholera, jaundice, and visceral inflammations. The vernal intermittents are most apt to become complicated with inflammatory affections; and those which occur in autumn are most frequently combined with disorders of the alimentary canal and ner- vous system. Paralysis and apoplexy, according to the observations of Dr. Macculloch, are by no means uncommon occurrences in inter- * Macculloch on Intermittent and Remittent Fever, &c. See also, Journ. General de Med. No. 291, foot note. Also, Gazette de Saute, No. 17. 108 INTERMITTING FEVER. mitting fever; and they occur, sometimes, as direct consequences of the influence of the miasmata, without any distinct febrile phenomena. Many of the affections which supervene in intermittents, appear to result from the inroads of the fever itself on the constitution; but the majority of these maladies, whether occurring as concomitants, sequelse, or substitutes of the fever, are, without doubt, direct con- sequences of the deleterious influence of the remote cause. Dropsy, jaundice, scirrhous, &c. are, probably, usually the result of the gene- ral febrile disease. Unquestionably, too, aneurismal enlargements of the heart and large vascular trunks, must be regarded as the con- sequence of the violent congestion of the blood which occurs in the internal organs during the cold stage. In the same way, apoplexy sometimes occurs in the commencement of intermitting fever; for the blood recoils so powerfully from the external to the internal vessels, in the cold stage of the disease, that those who are, in other respects, predisposed to determinations to the head, are liable to suffer apoplectic oppression of the brain from this cause. Dr. Mac- culloch warmly opposes the opinion, that in apoplexies of this kind, there is any particular congestion of blood in the brain. The cases which I have myself seen, however, do not permit me to doubt that they were essentially connected with cerebral pressure from inor- dinate vascular turgescence. It is not unlikely, however, that those apoplectic symptoms which occur as the immediate consequence of the powerful influence of miasmata on the brain, independent of chills, or torpor of the vessels of the surface, are in no way depend- ent on cerebral compression from sanguineous congestion. Paralysis, neuralgia, mania, &c, as well as the above named affec- tions of the alimentary canal, are, however, almost invariably direct malarious affection's^ occurring, with or without any manifest febrile phenomena; and frequently exhibiting their affinity to intermitting fever, by their paroxysmal and strictly periodical character. For a full exposition of the nature, phenomena, and management of these miasmal diseases, the reader is referred to Dr. Macculloch's Treatise on Intermitting and Remitting Fever. But if intermitting fever has a tendency to produce other affec- tions, it has been found also to remove various diseases of a chronic and obstinate character. Celsus observes, that intermitting fever is often remedial of itself. (Lib. II. cap. 8, p. 70.) The tendency of quartans to cure epilepsy, is mentioned by Hippocrates; (Epidem. 1.) and we are told that the celebrated mathematician De la Hire, was permanently relieved of an habitual and most violent palpitation of the heart, by an attack of ague of the quartan type. (Academ. des Sciences, l'An. 1718. Hist. p. 110.) Fordyce states, that rheuma- tism, cutaneous eruptions, hysteria and. indigestion, have been effec- tually removed by attacks of intermitting fever; and Vogel asserts that he has known asthma and hypochondriasis cured by this disease. Almost all writers, however, attribute much more sanative power in this respect to quartans than to either of the other two types. INTERMITTING FEVER. 109 Intermittents, when suffered to pursue their course without being controlled or embarrassed by external influences, appear to have a natural tendency to terminate spontaneously, after a certain number of paroxysms have been passed through. Quotidians, for instance, if they are simple and regular, will tend to terminate their course on the seventh day, and tertians on the fourteenth. Quartans will gene- rally run on to the sixth week. Of the natural tendency of the two former types to terminate at about the periods just indicated, I have the strongest conviction from my own observations. The disease may not generally terminate spontaneously at these periods, but its tendency to do so will be such, that if assisted by a proper febrifuge, it will not only more certainly be arrested, but a relapse wfll scarcely ever occur, unless the remote cause continues to act on the system. Every one who has had considerable experience in the treatment of intermittents, must have been struck with the great fre- quency of relapses, even where the patient has been removed out of the sphere of the influence of the remote cause. From what I have observed in relation to this subject, I will venture to say, that if the usual febrifuges were withheld until after the seventh paroxysm, such an occurrence would, under all circumstances, be comparatively very rare. I have already adverted to the tendency of intermitting fevers to relapse at stated intervals; and although I cannot undertake to reconcile the apparent opposition in these statements, namely, that fevers of this kind tend naturally to terminate and also to relapse at the septenary periods; yet of the truth of the observation I enter- tain the strongest conviction. Prognosis.—The intermittents of temperate climates are among the least dangerous of febrile affections. In hot latitudes, however, they often assume a highly malignant and fatal character. Death from a simple and mild intermittent does nevertheless sometimes occur; and when this happens, it is nearly always in the cold stage, and with symptoms of apoplexy. I have met with two fatal in- stances of this kind. The violent internal congestions which occur during the cold stage, are well calculated to produce cerebral op- pression and apoplexy, particularly in persons who are naturally predisposed to this malady. In general much less danger is to be apprehended from this disease in the young, robust, and vigorous, than in persons of feeble, nervous, and depraved habits of body. In individuals of the latter habit, there is sometimes not sufficient vital energy, to react and develop the hot stage, and they occasionally sink into a state of lethargy or fatal apoplexy. The more irregular an intermittent is, in relation to its type and particular phenomena, the more difficult in general it is to effect a permanent cure. Post- poning agues are more favourable than such as anticipate their parox- ysms. The latter tend to the continued form. A scabby and hu- mid eruption about the mouth and nostrils is a favourable sign. When habitual discharges, whether natural or morbid, re-appear after having been suppressed by the ague, perfect convalescence generally 110 INTERMITTING FEVER. soon follows. The state of the digestive functions has an important bearing on the prognosis of intermittents. So long as digestion is performed with considerable activity, and there are no decided marks of gastric irritation, very little difficulty in general will be expe- rienced in removing the disease. But when these functions are pro- minently deranged, and there are manifestations of much debility of the stomach, we may calculate on meeting with considerable diffi- culty in our efforts to prevent the return of the paroxysms; for even should a temporary stop be put to the progress of the disease, the liability to relapse in this state of the digestive apparatus, is such as to render the best directed treatment often abortive. •Delirium seldom occurs in intermittents, and when it does hap- pen, it must be viewed as unfavourable; and even more so than mere coma. In malignant intermittents, delirium is common; indeed, it may be regarded as almost peculiar to the worst varieties of this disease. Difficult and oppressed breathing, attended with hiccough and frequent deep sighing, is a bad sign. Sydenham observes, that a tumid and hard abdomen, with swelling of the tonsils, is in general indicative of a fatal termination. One of the most unfavourable signs is a profuse and prolonged colliquative and offensive diarrhoea. Bloody urine also is very unfavourable. The latter symptoms are almost exclusively confined to the violent intermittents of hot cli- mates. When, during the intermission, the patient remains very much debilitated and oppressed, and the feet and legs are oedema- tous, considerable danger may be justly apprehended. Tertians are, in general, more readily removed than quotidians, and quotidians than quartans. Intermittents not unfrequently change into the remittent form; and this conversion is, of course, always an unfavourable occurrence. When such a change is about to happen, the paroxysms of the intermittents are progressively prolonged until they run into each other. Simple tertians always reduplicate their type, before they assume the continued or remit- tent form. The conversion of intermittents into the remittent form, is particularly favoured by whatever is capable of causing or augmenting the general phlogistic condition of the system, and especially by the accidental supervention of some internal inflamma- tion. The unseasonable employment of tonics and stimulants is frequently productive of such changes in the form of the fever. Causes.—The only general cause of intermitting fever is koino- miasmata. Intermittents are the simplest, and in general the least dangerous of all the febrile diseases produced by this variety of mi- asmata. In the vicinity of marshes, we may often trace the various grades of miasmatic fevers from the most violent and fatal to the simplest and mildest varieties, as we progressively remove from the focus of the deleterious exhalations towards the circumference of its influence. On the borders of the soil, whence the miasmata ema- nate, if very copiously engendered, continued and highly fatal cases of bilious fever will prevail; at a greater or less distance from this INTERMITTING FEVER. Ill point, mild remittents will predominate; and at a still more remote situation, intermittents will be most common. From the same cir- cumstance, the first diseases which occur in miastic districts are generally intermitting fevers; as the season advances, remittents occur, and finally prevail with great violence; as the cold weather approaches, and the extrication of miasmata begins to diminish, intermittents again become more common, and the remitting fevers gradually disappear. The tendency of koino-miasmata to produce intermittents, is much enhanced by sudden changes of atmospheric temperature. Intermittents are never more prevalent than when the days are very warm, and the evenings and mornings cool and damp. In some instances, several weeks elapse between the reception or im- pressions of the miasm, and the occurrence of the fever. I have repeatedly known persons to be attacked with intermitting fever in this city, several weeks after they had been exposed to koino-mias- mata in the country.* Persons who have been exposed to mias- mata, should carefully avoid every thing capable of debilitating the system, and particularly the digestive organs, for at least two weeks after exposure. Although koino-miasmata may be regarded as incomparably the most frequent cause of intermitting fever, yet various other causes may, under favourable circumstances, give rise to this form of fever. Ritcher observes, that worms and other causes of intestinal irritation have been known to produce intermitting fever. He mentions, also, suppressed catamenia, and haemorrhoidal discharge, as well as the drying up of old ulcers, as occasional causes of intermitting fever. I have seen one instance, in a delicate child, where a distinctly formed ague was manifestly produced by intestinal irritation from too free an indulgence in irritating articles of food. An interesting case is related by Mr. Earle,t in which a regular intermittent was produced by the irritation of a small piece of dead bone in an old wound, and which was at once arrested on removing the irritating * Upon this point Dr. Macculloch differs, so far as I know, from every other writer who has attended to this subject. He maintains, that the interval be- tween the application of the miasmata, and the first manifestations of its morbific effects on the system, seldom, if ever, extends beyond twenty-four hours. " I know not," he says, " if physicians have fairly observed that the supervention of intermitting fever may be later than twenty-four hours from the exposure to the cause;" and he asserts that the attack of intermitting, as well as remitting fever, " sometimes instantaneously follows the application of the poison." That the febrific powers of miasmata may be manifested very soon after they are applied, cannot be questioned, but the assertion that the period between the reception of the poison, and its obvious effects, does not probably extend beyond twenty-four hours, is undoubtedly contradicted by almost daily experience in our own climates. \ Medico-Chir. Review, January 1827. 112 INTERMITTING FEVER. substance. It would seem that either the generation of miasmata, or their power of producing intermitting and remitting fevers, is greatly controlled by certain occult conditions, wholly unconnected with any appreciable circumstances, with regard to atmospheric tem- perature, or any of the other known requisites for the production of this poison. In certain districts of the temperate latitudes, malari- ous fevers will sometimes disappear, or become extremely rare, for a number of successive years; and then gradually become more and more common, until, in the course of a few seasons, they assume the prevalence of an epidemic; and yet, no material difference will be obvious between these periods of exemption from, and prevalence of disease, in relation to what are deemed the necessary concomitants for the production of miasmata. Proximate cause.—In relation to the proximate cause of this form of fever and of its periodicity, we may at once confess our entire ig- norance; for all that has hitherto been advanced in relation to these mysterious subjects, amounts to nothing more, at best, than some in- genious conjectures and hypothetical speculations, with a great deal of crude and absurd reasoning and idle suppositions. As to the sen- timents of Broussais, which place the proximate cause of this and all other fevers in an inflammation of the mucous membrane of the ali- mentary canal, it can neither be profitable nor interesting to repeat again what 1 have already advanced in refutation of its correctness. Treatment.—The treatment of intermittents must be considered under two distinct heads: namely, that which is proper during the paroxysm; and that which is to be employed during the intermis- sions, and upon which the radical cure of the disease depends. In the ordinary regular intermittents of the temperate latitudes, remediate interference during the paroxysm of the disease is ex- tremely uncommon, and is indeed very generally altogether unneces- sary. Nevertheless, where the febrile excitement becomes very violent in the hot stage; or where the system is so enfeebled that dangerous congestions and oppression occur during the cold stage, medicinal aid is not only proper, but sometimes absolutely essential to the safety of the patient. During the cold stage of an intermit- tent, the patient ought to be kept moderately warm; and as the thirst is generally very urgent, bland and warm drinks should be freely allowed. In general, however, stimulating drinks, and the appli- cation of much artificial heat, with the view of moderating the dis- tressing sense of cold, are improper; since they very rarely lessen the feeling of chilliness, and tend often considerably to increase the violence of the succeeding hot stage. These observations apply to the regular disease, occurring in individuals of sufficient vital energy to develop the hot stage, without any artificial support. When the patient is feeble, nervous, or exhausted, it will, generally, be beneficial to aid the vital powers during the cold stage, both by external and internal exciting agents, more especially, by the applications of ex- ternal heat. Without such aid, the cold stage will probably be INTERMITTING FEVER. 113 greatly prolonged, and the s)rstcm so oppressed, by internal conges- tions, as to prevent the regular development of the subsequent stages. Various means have been adopted for the purpose of curtailing the cold stage; and of these, emetics and opium appear to be the most efficient. An emetic administered at the beginning of this stage, will frequently put a speedy termination to its progress; and a full dose of opium, taken a short time before the expected occurrence of the chills, will generally have the same good effect. This latter remedy was particularly recommended by Dr. Trotter; and other eminent physcians have given their testimony in its favour. In de- bilitated and relaxed habits the exhibition of a grain or two of this narcotic, just before the accession of the chills, will generally prove decidedly beneficial. I have frequently resorted to it in cases of this kind, with obvious advantage. In persons of a full and vigor- ous habit of body, it will rarely do any good, and may readily do mischief by increasing the violence of the reaction and of the deter- mination to the brain, in the hot stage. Compression with the tourn- iquet, also, was some years ago, strongly recommended to the pro- fession, for arresting the cold stage of intermittents, by Dr. Kellie.* I have known it to be employed in four cases, and although the effects of it were by no means equal to those which Dr. Kellie as- cribes to it, there was, nevertheless, a manifest impression made on the violence and progress of the chills. Dr. Kellie asserts, that by obstructing the circulation in an upper and in a lower extremity, by means of a tourniquet, we may in general, stop the cold stage in three minutes; and that if the compression be made immediately previous to the accession of the cold stage, it will be entirely pre- vented. The limited experience which I have had in relation to this practice, does not confirm this very favourable account of its effects; although some, and occasionally perhaps considerable advantage may, no doubt, be obtained from it. I should apprehend, however, that in vigorous and plethoric subjects, considerable danger must attend this practice, from the tendency which it must have to favour vascular tur- gescence of the brain; and thereby dangerous oppression or apoplexy. Within the last two years, Dr. Mackintosh has published some highly interesting observations on the utility of blood-letting in the cold stage of agues, which, though contrary to the sentiments uni- versally entertained, concerning the character of this stage of febrile development, and the known tendency of blood-letting, are never- theless too strongly confirmed, by well attested facts, to justify us in rejecting them, without farther experience. "There are few things," says a late writer, "more repugnant to the imagination of a medical man than that of venesection in the cold stage of intermit- tents. Books and lectures all inculcate a diametrically opposite prac- tice. We see the face and the surface of the body pale and cold; * Medical Commentaries for the years 1794-1797, by Dr. Duncan of Edin- burgh. Vol. I.—\5 114 INTERMITTING FEVER. the pulse feeble and quick; the teeth chattering; the whole body shivering; and the suffering patient huddling himself up in all the clothes he can find to keep the spark of life from being extinguished! The very idea of abstracting the vital fluid, which seems almost en- tirely to have vanished, is horrible. But yet, when we come to re- flect that the blood has only shifted its place from the circumference to the centre, and that the internal vessels and organs must now be gorged with this -fluid, and as it were in a state of suffocation, there is nothing very incongruous in the attempt to relieve the suffering organs, by abstracting a portion of blood from the general circula- tion." Moreover, when we advert to the circumstance that blood- letting has been strongly recommended and successfully employed, to remove the internal congestions which occur in typhus fevers, where there is generally an actual deficiency or impairment of the vital energies, it does not appear so very extraordinary, that the same means should be adequate to restore the equilibrium of the cir- culation, or to remove the internal congestion in an ague, where the vital powers are not impaired, but only oppressed. Dr. Mackin- tosh states, "that he has seen men in the most severe sufferings from the chills relieved after the abstraction of six, eight, and ten ounces of blood; and he has known three ounces to suffice. The relief, which is the most perfect relief that can be conceived, is so sudden, when a good orifice is made, that it has surprised and delighted every one who has seen this practice." Dr. M. had this practice tried on himself in 1810; and, although bark and other remedies had entirely failed, he found that before twelve ounces of blood were drawn, "the rigors ceased with all their unpleasant accompaniments," and neither the hot nor the sweating stage ensued. "A pleasant sense of heat succeeded the painful one of cold; and, instead of weakness, he was sensible o'f an acquisition of strength." He afterwards bled many other patients in the cold stage of this malady, and uniformly with the same favourable results. This practice was put in operation in the Royal Ordinance Hospital, of Edinburgh, in the presence of many medical gentlemen, and must, therefore, be regarded as amply attested.* In a single instance I have drawn blood in the cold stage of this disease; and in this case, it moderated the violence of the chills and curtailed their duration in a manifest degree. I have not since had a favourable opportunity of repeating this practice, but from the result of this case, and the strong testimony of Dr. Mackintosh, I feel inclined to give it a further trial, whenever an opportunity of do- ing so shall present itself. It cannot be presumed, however, that this practice is equally well adapted to all cases. Dr. Zabriskie, of New York,states that he found it, in general,decidedly beneficial in persons " of a plethoric, full habit, with strong pulse, and not enfeebled by in- temperance or by the fever." In patients enfeebled by intemper- * Ed. Med. and Surg. Journ. April, 1827; and Medico-Chir. Rev. Julv, 1827, page 186. J' INTERMITTING FEVER. 115 ance, or the long continuance of the fever, with a small and weak pulse, bleeding in the cold stage sometimes gave rise to alarming symptoms.* • In the hot stage, it sometimes becomes necessary to moderate the violence of the febrile excitement, especially when delirium or alarm- ing local determinations take place. Blood-letting isof course the most direct and efficient means for this purpose, and where the indications for antiphlogistic measures are strong, it ought to be promptly em- ployed. In agues of a decidedly phlogistic diathesis, blood-letting during the hot stage will often contribute considerably to the suc- cessful employment of the bark in the intermission. I have some- times known the bark promptly efficient in arresting the disease after a copious blood-lettting during the paroxysm, where it had pre- viously failed. In cases attended with a very hot and dry skin, and a full and vigorous pulse, cool, bland and acidulated drinks are both grateful and salutary. A draught of cold water while the skin re- mains dry, will often speedily subduct the febrile heat and predis- pose to perspiration. It may also be proper, in instances of very high general febrile excitement, to exhibit some of the refrigerent diaphoretics—such as nitre—antimony—the saline effervescing mix- ture.t As soon, however, as the skin begins to be moist, cold drinks must be withheld. During the last or sweating stage, we may allow tepid drinks of a bland character freely. When the stomach is extremely irritable—giving rise to frequent and violent vomiting in the cold or hot stage, tepid diluents should be given, until there is reason to think that the bile is discharged. Opium is, perhaps, our best remedy for checking excessive vomit- ing in this disease. This article does not often aggravate the vio- lence of the reaction, when given in the hot stage, as might be apprehended. Indeed, Dr. Lind zealously advocates the propriety of exhibiting a full dose of opium, soon after the hot stage is deve- loped, as a general practice. He asserts, that it takes off the burning heat of the fever, hastens the accession of the sweating stage, and often produces a soft and refreshing sleep, from which the patient awakes free from all complaints, and in full perspiration. He thinks, moreover, that the use of opium in the hot stage tends to obviate dropsy and jaundice. I have given opium in the hot stage to check vomiting, and have always found it to answer this purpose very promptly and completely, without any unpleasant consequences. I cannot, however, think that opium is a proper remedy in the hot stage of ague, unless it be in broken down constitutions, or in such as are * Amer. Jour, of Med. Scien. vol. xiii. page 80. | The following mixture is an excellent remedy for this purpose— R—Spirit. Minderiri. giv. Spirit. Nitr. Dulc. gii. Vin. Antimon. 31. Syrup Limonis, §i—M. Take a table-spoonful every hour. 116 INTERMITTING FEVER. feeble and exhausted by previous injurious influences—or unless it be employed to remove some accidental affection of a distressing or dangerous character. In cases where the reaction of the heart and arteries is incomplete, and where much internal congestion continues to exist through this stage, opium is, without doubt, a valuable remedy. To put a stop to excessive vomiting in this, as well as in other diseases, not attended with phlogosis of the mu- cous membrane of the stomach, I know of no medicine which is more promptly and certainly effectual, as a solution of camphor in sulphuric sether, in the proportion of two scruples of the former to an ounce of the latter; of which twenty or thirty drops may be given with about ten grains of calcined magnesia every half hour until the vomiting is arrested. I have rarely found the second dose necessary. Whatever advantage may result from remediate treatment during the paroxysm, universal opinion concurs in regarding the inter- mission as the proper period for the safe and certain radical treat- # ment of intermitting fevers. In prescribing for the radical cure of intermittents, it is of no small consequence to attend to the particu- lar character of the disease in relation to the four modifications or varieties mentioned above; for each of these requires some peculiar modifications of treatment. 1. The inflammatory variety, as has already been stated, is marked by symptoms during the intermission, which indicate an irritated and phlogistic condition of the system, incompatible with the salutary influence of the bark and the other febrifuge remedies of this kind. In this modification of the disease a strictly antiphlogistic treatment must precede the employment of the tonics usually re- sorted to. The patient must be put on an antiphlogistic regimen; one or two cathartics, composed of calomel and jalap—or calomel, succeeded in a few hours by an ounce of Epsom or Glauber's salts, will be proper; and where the inflammatory diathesis is very con- spicuous, blood-letting, nitre, antimonials, &c. are often indispensable. In cases of this character, blood-letting will, in general, prove most efficient in reducing the phlogistic habit, when it is practised pretty copiously during the hot stage. In cases of vernal intermittents, in which the bark or quinine had failed in consequence of the general irritated and phlogistic condition of the system, I have succeeded perfectly with these febrifuges, after the patient had taken one of the following powders,* every two hours during an intermission, and a small bleeding in the hot stage of the succeeding paroxysm. •In the congestive and malignant varieties of ague, it will seldom be proper to lose much time in preparing the system for febrifuge tonics. In such cases, the powers of the system must be economised, and tonics early and liberally resorted to. In the gastric modifica- * R.—Pulv. nitrat. potass® 31SS. pulv. doveri gr. vj. calom. gr. vj.—M. In chart. No. vj. dividend. INTERMITTING FEVER. 117 tion, which is most commonly met with in the temperate latitudes, there exist obvious indications of gastric impurities and disorder— such as nausea; bilious vomiting and purging; foul tongue; loss of appetite; pains in the stomach and bowels; bitter or depraved taste, &c. In intermittents of this character, it will be peculiarly proper to attend to the state of the alimentary canal, before the bark or tonic remedies are resorted to. Mild mercurial purgatives are generally decidedly beneficial. In some instances, it may be necessary to repeat them several times before the bowels are brought to a proper state for the employment of febrifuges. Emetics, too, will often contribute much to the success of the bark or quinine. In inter- mittents of a well-formed inflammatory character, there are seldom any unequivocal manifestations of gastric impurities, and hence these evacuations are much less useful or important in them than in the variety I have termed gastric. Among the various articles which have been recommended for the cure of intermittents, the Peruvian bark and its preparations, is, unquestionably, by far the most important. Within the last ten years, the sulphate of quinine has, in a great measure, taken place of the bark in substance, and in many respects, this preparation pos- sesses important advantages over the crude material. It has indeed been said, that the bark itself will sometimes remove the disease where the quinine has failed; but the converse may be said with equal correctness; for I have, in several instances, succeeded with the latter, after the former had been used in large doses without success. Mr. Valpes, of Naples, in a recent communication to the French Royal Academy of Medicine, states, as the result of his inquiries, that the sulphate of quinine is preferable to the cinchona, in inter- mitting fevers, whilst the latter is preferable in the fevers formerly denominated putrid* and which are produced by idio-miasmata.t From my own experience, I have not been led to think that there exists any essential difference in the febrifuge virtues of these two remedies; but as the quinine is much less nauseous, and can be given in sufficient doses in a very small bulk, I should, from these ad- vantages, always prefer it to the bark in substance, unless some idio- * Revue Medicale, Mai. 1828, p. 306. f In March, 1825, the number of lunatics brought to the Maison d,Aversa in the kingdom of Naples, was so great, that it was found necessary to lodge them in a convent, which was not properly prepared to receive them. The most filthy of these unfortunate beings were put into a small dormitory, which was in a state of extreme filthiness. A fever soon broke out among them, which was at first regarded as a petechial fever, and was treated by antiphlogistics. The disease made a rapid progress, and became unusually fatal. The sulphate of quinine was finally employed, but this appeared rather to aggravate the symp- toms, than to afford any advantage. At last, the bark in substance was given, and immediately resulted in the happiest effects.—Revue Medicale, 1828, Mai. 306. 118 INTERMITTING FEVER. syncracy exist against its influence, which can be ascertained only by experience. Much difference of opinion has been expressed, both in relation to the period of the disease, and the particular time of the intermission, at which the bark may be most effectually administered in this form of fever. It has been contended, that it will generally be much better to suffer several paroxysms to take place, before any attempt is made to arrest their recurrence. Recamier has recently advocated this practice, as both the most effectual and the safest to the future health of the individual. I do not at all doubt the correctness of this mode of management. Unquestionably, a great majority of our ordinary agues may be immediately arrested, and with perfect safety, by giving the bark, during the first or second intermission; but in this case relapses are much more common than where the disease has been suffered to run on to the fifth or seventh paroxysm. I have found agues arrested after the first or second paroxysm, relapse again and again, until they were suffered to run on to the fifth or seventh day, when a few doses of quinine put a permanent stop to their progress. It has long been my practice, when I have met with relapsing agues, to suffer them to run on through five or seven paroxysms, before any attempt was made to arrest them, and I have invariably found this plan permanently successful. In cases which require prepara- tion, especially in inflammatory intermittents, delay is of course essential, before the bark can be employed with propriety. I would not, however, lay it down as a general rule, that the disease should be suffered to run on through five or seven paroxysms; for where the apyrexia is very complete, and the patient experiences no feelings of illness during the intermissions, the bark may almost always be given with complete success, as soon as the bowels are evacuated by a suitable cathartic* In instances of an opposite character, or such as have shown a tendency to return after a week or two, it will be very difficult to put a final stop to the paroxysms, if the febrifuge be employed during the first or second intermission. A case came under my notice, during the preceding autumn, which had already relapsed four times, and always punctually on the seventh day. After each relapse, the patient took quinine in full doses, which always arrested the disease for the short period mentioned. When he applied to me, I advised him to suffer his disease to go on for some time, without any other medicine than a mild purge every other day. He did so; and on the ninth day, the disease left him spontaneously and permanently. The foregoing observations apply, of course, to the regular in- termittents of the temperate latitudes; for, in that rapid and fatal variety which is termed malignant, no time should be lost by pre- paratory measures, but immediate recourse had to large and frequent doses of the bark, as soon as a favourable intermission occurs. The * R.—Pulv. jalap . . . Calomel aa. gr. x. M. INTERMITTING FEVER. 119 same rule applies to the disease occurring in very feeble, nervous, and exhausted subjects; for, unless it be speedily removed, the system may sink under the repeated shocks of the paroxysms. With regard to the particular period of the intermission at which the bark may be most successfully given to arrest the succeeding paroxysm, a diversity of sentiments have been expressed by writers. Some have advised its employment in large doses immediately after the sweating stage has passed off; whilst others recommend it to be given largely, " as near to the time of the expected paroxysm as the condition of the patient's stomach will allow," (Cullen.) There are others, again, who think it best to exhibit the bark in divided and frequent doses, throughout the whole period of the intermission. (Fordyce.) A few years ago, Dr. Ridgway published some cases, which go to show, that one large dose of cinchona given as near as possible to the commencement of the approaching paroxysm, will as certainly avert the paroxysm, as when given in repeated doses throughout the intermission.* Since Dr. Ridgway's publication, Dr. Brown, of Boston, has published a small work, in which he ad- duces testimony of a similar purport.t According to Dr. Brown's experience, two or three grains of the quinine taken just as the first symptoms of the approaching paroxysm are experienced, will, when followed up at intervals with a second, third, and sometimes a fourth dose, almost invariably put a stop to the disease. When given just as the cold stage commences, " its influence over the rising symp- toms becomes manifest in a few minutes; the pulse becomes more full and distinct; the respiration more easy; the skin acquires its natural temperature; and, in eleven minutes in his own case, not one unpleasant symptom remained." This state, however, generally continues but a short time, and it becomes necessary to repeat the dose, sometimes three and even four times before the paroxysm is subdued. Dr. Ridgway ga"ve an ounce of the bark at once, as soon as the premonitory symptoms of the paroxysm were felt, and always found it to prevent the attack. There can be no doubt that the dis- ease may be speedily arrested in this way; but it may be reasonably questioned, whether it possesses any real advantage over the plan of exhibiting this febrifuge in efficient doses during the latter period of the intermission. I have generally prescribed the quinine in two grain doses every hour, commencing about six hours before the be- ginning of the approaching paroxysm; and I have had no cause to be dissatisfied with the consequences. Indeed, I have reason to apprehend that a large dose of quinine given during the chills, is calculated to produce very disagreeable effects. In two instances, one a delicate married lady, and the other a lad about twelve years old, a most singular and raving species of maniacle affection ensued, apparently from taking large doses of this medicine after the chills * London Medical and Physical Journal for April, 1825. f A Treatise on repelling the Paroxysm of Intermittent Fevers. Boston, 1826. 120 INTERMITTING FEVER. had commenced. In both instances this alarming mental disturb- ance continued for several hours. I may be wrong in ascribing it to the causes here assigned, but the circumstances strongly favoured the suspicion. Whatever views we may adopt, however, with regard to the time at which it may be best to begin with the bark or quinine, there can be no doubt concerning the propriety of giving large doses,* in such a manner as to make a decisive impression on the system in the lat- ter period of the intermission. I am well satisfied that two or three large doses—three grains of the quinine, given two or three hours before the paroxysm, will do more towards averting it, than a larger quantity exhibited in small doses throughout the whole interval of the apyrexia. In relation to the propriety of employing emetics and cathartics as preparatory measures for the use of the bark, au- thors express contradictory opinions. Unquestionably, where the signs of gastric impurities are conspicuous, and there exists no urgent necessity from the nature of the case, to arrest the disease promptly, it will be proper to evacuate the alimentary canal previous to the employment of the bark. These evacuations will also be useful in cases where the inflammatory habit is so strong as to prevent a com- plete apyrexia. Nevertheless, in the ordinary cases of the disease, where there are no signs of a loaded state of the bowels, and the apy- rexia is very complete, the bark may be successfully employed without either previous purgation or emesis. Upon the whole, however, I should in all instances of this disease, not attended by malignity or great prostration, prefer one or two mild cathartics, before the bark is taken, for the reasons already mentioned. The Peruvian bark has been frequently accused of having a tend- ency to produce visceral indurations and other unpleasant conse- quences, such as rheumatism, dropsy, &c. This accusation is, how- ever, wholly unfounded. No doubt, indeed, can exist that these and other injurious consequences may be produced by the injudi- cious employment of this remedy. When given, for instance, in agues, attended with strong marks of an inflammatory condition of the system, without proper antiphlogistic preparatory measures, we can readily conceive that the bark would favour the natural tendency of such cases to terminate in these disorders. In this respect, how- ever, the bark does not differ from other tonic and stimulating reme- dies; for it is not by any thing peculiar in the bark that these effects are produced, but simply by the power it possesses, in common with the majority of febrifuge remedies, of favouring the phlogistic dia- thesis, and the progress of obscure inflammations. The bark is now generally given by itself. Formerly it was cus- * If the bark in substance be employed, not less than two drachms ought to be administered at each dose. Such doses taken at intervals of an hour, or an hour and a half, within the last five hours of the intermission, will, perhaps, do all that can be effected by bark in this disease. INTERMITTING FEVER. 121 tomary to give it in conjunction with various other remediate arti- cles which were thought to augment its febrifuge powers. It is extremely doubtful, however, whether any combinations can mate- rially improve its virtues; and unless some particular circumstance be present which may render the use of other remedies proper, or unless the bark by itself produce unpleasant or injurious effects on the alimentary canal, it will probably be best to employ it singly. When it causes much constipation, it may be usefully given as follows: R.—Pulv. cinchon. condam. 3j. --- rhei. £ss. --- muriat. ammoniae gj.—Misce. In chart. No. iv. dividends. One to be taken every hour or two. When the bark purges, it should be given with small portions of Dover's powder, or opium. The former especially, acts beneficially in such instances, five grains of which may be given at each dose. Alkaline remedies become necessary in cases where there are signs of much acid in the stomach. The subcarbonate of potash is an ex- cellent adjuvant to the bark in cases of this kind. From ten to twenty grains of the alkali may be given with each dose of the bark; and to prevent this from acting on the bowels, which it is apt to do, it is generally necessary to make a triple compound—viz. bark, sub- carbonate of potash, and opium, or what is better, confectio opii. When the stomach is irritable, the bark will generally be speedily rejected. In this case we may sometimes cause it to be retained by uniting it with some aromatic substance, such as serpentaria, or cloves, or nutmeg, or the calamus aromaticus. The serpentaria is, perhaps, the best aromatic adjuvant to bark, where the stomach is too weak to retain it singly. I have, however, always found small doses of opium to answer better than any other remedy for this pur- pose. The addition of powdered black pepper answers extremely well in cases where the vomiting arises simply from gastric debility. Where, however, this occurrence depends on a highly irritated condition of the macous membrane, neither this nor any other aro- matic can be proper. In this condition, indeed, the bark itself can- not be employed until the gastric irritation is subdued by leeches, blisters, or cupping over the epigastrium. The employment of the quinine is much less apt to produce the inconveniences just mentioned than the bark in substance; but even this preparation will sometimes produce violent purging or vomiting —several very violent instances of which I have encountered in my practice. Formerly it was customary to employ the decoction, or the tincture, or what is better, both in union with each other, where the bark in substance could not be conveniently administered, or where the stomach rejected it. Since the introduction of the qui- nine into practice, however, this mode of exhibiting the cinchona Vol. I.—16 122 INTERMITTING FEVER. has been but little employed; nor does it appear probable that any circumstances can occur which may not be as well met with this very convenient and concentrated preparation, as with either the decoction or the tinctuue of the bark. The most convenient and elegant formula for exhibiting the quinine, is, perhaps, the following: » R.—Sulphatis quinae gr. xvj. Elixr. vitriol gtt. xvj. Syrup, limonis gj.—M. Dose, a tea-spoonful every hour or two for an adult. As this mixture, though a very neat and concentrated one, is sometimes much objected to on account of its bitterness, especially by children, I have generally prescribed it according to the follow- ing formula, by which almost all the bitterness is wholly removed: R__Sulphat. quinae gr. vj. Elxir. vitriol gtt. x. Pub. extract, glycyrrh gjss. Aq. fontan^e ^jj.—M. Dose, a tea-spoonful for a child between two and five years of age. In cases of ague, which, from long continuance, or from some pre- vious malady, are attended with visceral indurations or enlarge- ments, the quinine or bark must be given, either after a gentle mer- curial course, or in conjunction with mercurial remedies. The blue mass will in general answer best for this purpose, as it is mild, and less apt to pass off by the bowels than calomel. In many instances of this kind, the bark will, in fact, fail entirely in putting a stop to the continuance of the disease; and I have known it to do manifest mischief even when given in conjunction with mercury. In such cases, mercury is the appropriate remedy; and, under careful ma- nagement, will rarely fail to arrest the disease. From three to five grains of the blue mass, taken thrice daily, until the gums become slightly affected, will generally suffice to remove the complaint. Besides bark and its preparations, a vast variety of other reme- dies, drawn both from the mineral and vegetable kingdoms, have been employed with success, in the treatment of intermittents. As nearly all of them are, however, confessedly inferior to the cin- chona, it will be sufficient here, barely to mention them. The most efficient of these articles are the following: viz. The barks of the dog-wood, (cornus florida;) of the American tulip poplar, (Lirio- dendron tulipfera;) of the horse-chesnut, (E. hypocastanum;) of different oaks; of different species of willow; the Virginia snake- root; colomba; gentian; quassia, &c. Coffee is highly recom- mended by Grindel; given in doses of from fifteen to twenty grains every hour, it is said almost invariably to arrest the disease, (Richter.) The black, or cellar spider's web, is highly recommended by Dr. INTERMITTING FEVER. 123 Robert Jackson,"* as a remedy for intermittents. He is of opinion, "that it prevents the recurrence of the intermittent paroxysms more abruptly and more effectually than even bark or arsenic." I have employed this article in six cases; two of these were speedily cured, the others resisted its powers entirely. Shrader speaks of this arti- cle as an effectual remedy for agues, in his Dispensatory, published as early as 1644. It certainly possesses very considerable powers* in allaying morbid irritability, and in calming the excitement both of body and mind. In my own person, it produces the most de- lightful state of mental and corporeal tranquillity, far exceeding that which is caused by opium.t It is given in five or six grain doses every three or four hours. The muriate of ammonia is favoura- bly mentioned by Richter as a remedy in this disease.:): He consi- ders it especially useftil in agues attended with gastric impurities, or a loaded state of the bowels; and in cases connected with visceral indurations. It should be given in union with quinine or cinchona in substance. I have used it myself, in cases attended with indura- tion and enlargement of the spleen, and with the most favourable effects. The muriate of ammonia is, perhaps, the most powerful remedy we possess for resolving indurations, when given in very large doses internally. In Germany, it has of late years been much and very successfully used in enlargements of the prostrate gland, and other similar affections. In my own practice, I have had the most satisfactory proofs of its very excellent powers in this respect. I have given it to the extent of three drachms daily. In intermit- tents, with indurated spleen, it may be given in combination with quinine, in the proportion of twenty grains of the muriate of ammo- nia to two grains of the latter. The former ought to be continued after the quinine may no longer be necessary—that is, after the paroxysms have been arrested. Salicia has recently been much ex- tolled for its excellent febrifuge powers. It is given in doses of from twenty to forty grains. M. MiqueJ has published an account of its use in this disease, from which it would appear, that it is little, if in any degree, inferior to the quinia in intermittents. It has also been used by Dr. Gerardin with marked success. Other physicians in France and Italy have employed it for the cure of intermittents, with satisfactory results. Dr. Berti, the erudite editor of Burserius' posthumous works, speaks very favourably of its febrifuge virtues.§ Among the mineral preparations, arsenic is, undoubtedly, the most efficient, with the exception, perhaps, of the sulphate of zinc. Arsenic was employed in this disease near a century ago, by Jacobi;|| * London Medical and Physical Journal, vol. xxi. f Eberle's Therapeutics, vol. ii. p. 121, first edition. % Specielle Therapie, vol. ii. § North Araer. Med. and Surg. Jour., vol. x. p. 192. || De Arsenico sale alcalico domiti usu interno salutari.—(Acta Academ. Elet. Mogunt. torn. i. p. 116.) 124 INTERMITTING FEVER. but it was not till Fowler and Brera published their experience, in relation to its medicinal powers, that it was brought into general notice as a remedy in agues. It is, unquestionably, a very efficient remedy in this disease; but, in individuals of a cachectic habit, or where there is a scorbutic tendency, it is apt to cause dropsical effu- sions, as well as great debility and symptoms of general depravation of the system. It appears, moreover, to be improper in phthisical constitutions, and where a strong phlogistic tendency prevails. Of the tendency of arsenic to produce anasarcous effusion, I have had a strong illustration within the present year. I prescribed Fowler's solution to a syphilitic patient, and, although his nodes and nocturnal pains were removed, he became universally anasarcous. Arsenic appears to be best calculated to remove this disease without detri- mental consequences, in individuals of a firm atid vigorous constitu- tion. The usual mode of prescribing it is in the form of Fowler's solution, or the liquid arseniate of potash. From eight to twelve drops may be given every four or five hours during the intermission. I have generally given it in substance in union with opium, formed into pills in the proportion of one-tenth of the oxyd of arsenic, to one-fourth of a grain of opium every three or four hours during the apyrexia. Bietts' arseniate of ammonia is, I think, decidedly the best arsenical preparation for internal use. Since the publication of the first edition of this work, 1 have employed this arseniate, in various affections—particularly in an instance of periodical neuralgia, and in several instances of herpes, with peculiar advantage.* The sulphate of zinc is an excellent remedy for the cure of inter- mittents. I have very rarely failed to arrest the disease as promptly with it as with quinine. Dr. Firth, in a letter to Dr. S. Mitchell, of New York, dated Calcutta, 1805, speaks in the most favourable terms of this article as a remedy in intermittents. He asserts, that while prescribing in the Philadelphia Dispensary, he found it to cure cases in which both the ba»k and the arsenic had failed ;t Mr. Brand also observes that "in the cure of intermittents, the sulphate of zinc is an admirable tonic." He gives the following formula for using it: R.—Zinci sulphatis, gr. jj. Aq. cinnamon. ----distillat. aa ^jss. * This preparation is made by dissolving one part of the oxide of arsenic in four parts of nitric acid, with half a pint of muriatic acid. This solution is then to be saturated with carbonate of ammonia. The supernatent fluid must be slowly evaporated until the crystals of the arseniate of ammonia are formed. One grain of this salt is to be dissolved in an ounce of distilled water, to which a small portion of the compound tincture of lavender may be added. Of this solution, from thirty drops to one drachm may be given, in divided doses, in the course of twenty-four hours.—Casper's Charakteristik der Franz. Med. p. 204. t New-York Medical Repository, 1806. INTERMITTING FEVER. 125 Tinct. calombae gj.—M. Fiat mistura. A table-spoonful is to be taken every three or four hours. I have hitherto usually' employed it according to the following formula. R.—Sulphat. zinci, gr. x. Pulv. capsici. ann. 3jj- Conserv. rosar. q. s.—M. In pil. No. xl. divid. S. One to be taken every two hours during the intermission. Black pepper, also, is strongly recommended by Dr. L. Frank for the cure of intermittents; and my own experience has afforded me several examples of its usefulness in this way. It is given in doses of from five to ten grains every two or three hours, either alone or in combination with some of the bitter tonics.* Tartar emetic has recently been successfully employed in inter- mittents by Recamier, at the Hotel DieuA Out of seven cases, five were quickly cured by tartar emetic given in ptisans, so as to produce both emetic and purgative effects. This article has also been employed externally with complete success in this disease. Dr. Pommer states, that in the winter of 1815, he was frequently disappointed with the use of the cinchona, in the intermittents which occurred in the army of Wurtemburg, encamped on the Loire and Allier. Observing "that the fever generally disappeared on the eruption of pimples or pustules on any part of the body," he was induced to try what an artificial eruption would do towards curing those cases that had resisted the regular treatment. He accordingly directed frictions with the tartar emetic ointment on the epigas- trium, and found it successful in every case as soon as the pustules appeared. ± There are few diseases over which the imagination exercises a more powerful controlling influence, than intermitting fever. In all countries and ages this malady has been peculiarly favourable to the extravagant pretensions of superstition and imposture. Amulets and the most absurd practices have been always more or less in vogue, among the common people, as means for arresting the pro- gress of this disease; and the reality of a mysterious power in these spells, is sufficiently demonstrated to the minds of the vulgar, by the occasional disappearance of the disease under their occult influ- ence. So intimate and strong, indeed, are the relations which subsist between the physical and moral elements of our nature, that there are few, if any diseases, in which we may not derive important ad- vantages, from calling to our aid the invigorating powers of hope, or dissipating the depressing emotions of sorrow and fear, and * Journal Complement, du Diction, des Sciences Med. No. 22. | Revue Medicale for December, 1826. X Journ. der Practischen Heilkunde, 1823. 126 INTERMITTING FEVER. ?1 diverting the mind from the causes, phenomena, and probable con- sequences of the disease, to objects of a more pleasing and hope- inspiring character. Any strong mental emotion occurring shortly before the usual period of the paroxysm will sometimes be sufficient to prevent its accession. It is especially, however, that condition of the mind which constitutes faith, or strong belief—and which the ignorant frequently yield to the most absurd practices, that opposes the strongest and most effectual barrier to the progress of this and other periodical affections. Dr. Macculloch asserts, however, that the curative effects of moral influences of this kind, are almost entirely limited to primary attacks, " or those which have, at least, not re- lapsed often;" and he adds, that they are very seldom successful except in cases where all the circumstances of the disease are re- gular. The periodical affections, mentioned under the head of anomalous or masked agues, often disappear spontaneously after having conti- nued for some time. This is particularly the case with the periodi- cal neuralgic affections arising from the influence of miasmata. In some instances, however, they assume a persistent course,and yield only to proper remedial impressions. In general, the most efficient remedies for the cure of these affections are the same that are most effectual in regular intermittent fevers. A few full doses of quinine are sufficient often, to remove periodical hemicrania, tic douloureux, or sciatica, without any other auxiliary remedies. In some instances of this kind, arsenic is peculiarly beneficial. Dr. Macculloch, in re- ference to the use of bark and arsenic in these affections, observes, " that there are two leading circumstances under which they often disappoint us. This happens when the attacks of the disease are very irregular; and, secondly, when the disorder is of very long standing; while in exact correspondence with intermittents, these two states are very commonly united." In such irregular forms of miasmal disease, a "single blood-letting will sometimes render the type regular," and this being effected, the tonics just mentioned will frequently prove effectual. The constitutional influence of mercury, also, " will sometimes cause these tonics to be efficacious when they have failed before." (Macculloch.) The sequela of this form of fever are often both obstinate and dangerous in their consequences. The most common of these mor- bid consequences of agues are:—cedema of the feet and legs; enlarge- ment and induration of the liver and spleen; jaundice; dropsy; and a general broken down state of the constitution. Authors men- tion other sequela of this disease—such as tympanitis, hemicrania, deafness, vertigo, paralysis, and epilepsy. The dropsy and jaun- dice, which occasionally supervene after very protracted agues, de- pend, no doubt, most commonly on the visceral indurations pre viously produced by the fevers or the miasmata. In nearly all these secondary affections, mercury may be regarded as our principal INTERMITTING FEVER. 127 curative means. A gentle alterative course, will often suffice to remove most of these affections—especially the visceral obstructions, and the disorders which depend on them. Four grains of blue mass, with two of pulv. ipecacuanha, ought to be taken every night i>n going to bed, and a dose of salts taken every fourth or fifth day. When the disorder is obstinate, and does not show a disposition to yield to this moderate mercurial influence, two or even three pills may be taken daily, until the gums begin to exhibit marks of its in- fluence on the system, when they should be discontinued, and re- sumed occasionally, so as to keep up a very moderate degree of the mercurial action. Some mild bitter infusion may be taken in mo- derate doses twice or thrice daily, during the use of the mercury. I have already mentioned the muriate of ammonia, as a valu- able remedy for the removal of visceral indurations. The formula which I have employed with great success in cases of this kind, is as follows: R.—Muriat. ammonias, ^ss. Pulv. extract, glycyrrh. ^j. Tart, antimonii. gr. j. Aq. fontanae, §viii.—M. ft. S. Take a table-spoonful every four hours during the day. Perhaps the most effectual remedy we possess for the removal of enlargement and induration of the spleen, arising from miasmata or intermitting fever, is iodine. I have employed it in one case, of long standing, with decided advantage, after mercury, the muriate of ammonia, antimony, &c. had been unsuccessfully used. From eight to ten drops of the tincture of iodine should be given three times daily, and a mild unirritating and digestible diet enjoined. We may also use the iodine in the form of frictions over the left hypochondrium;* but I apprehend the internal use of it will in gene- ral prove most effectual. Tartar emetic, in very small but frequent doses, forms, also, a very useful medicine in cases of this kind—more especially for the removal of that dry and icterode state of the skin, with oedema of the feet, which is so common a consequence of protracted agues. The best mode, perhaps, of administering this article in these affec- tions, is to dissolve it in a large quantity of water, or some mild and pleasant ptisane. I have generally directed one grain of tartar emetic to be dissolved in about three pints of water, and to be used freely as common drink. By continuing this drink, so as to con- , sume at least a quart in twenty-four hours, for eight or ten days, the skin generally becomes clear; the bowels regular; the cutaneous * R.—Hydriodat. potassae, 9jj. Axungiae, £jss. ^ Liq. potas. caust. gtt. v—M. Rub in, the size of a nutmeg of this ointment three times daily. 128 REMITTING FEVER. transpiration natural; and the enlarged spleen, or liver, manifestly diminished in size and hardness. Relapses are very apt to occur after the paroxysms have been arrested. The circumstances which seem most capable of causing a relapse, are: exposure to cold and damp air; errors in diet and drink; the depressing passions, and renewed or continued exposure to the influence of koino-miasmata. All these causes ought, there- fore, to be carefully avoided after the disease has been arrested, par- ticularly where previous relapses have already occurred in the same case. It is especially important to avoid every thing which is cal- culated to derange the digestive organs. But nothing, I conceive, is better calculated to obviate relapses, than a delay in prescribing febrifuge remedies until the apyrexia is complete, and all signs of a general or local inflammatory condition are removed, and the disease has run on at least over the seventh paroxysm in quotidians, and the fourth in tertians. When an ague assumes a chronic character, none of the usual febrifuge tonics will do more than to cause a temporary suspension of the paroxysms. In cases of this kind a gentle saliva- tion will usually do more good than any other mode of management we can adopt. Even if the mercurial influence should not put a permanent stop to the progress of the disease, it will be apt at least to render the system more susceptible to the remedial operation of the bark and arsenic, and thus contribute materially to the ultimate removal of the disease. CHAPTER VI. REMITTING FEVER. Bilious Fever; Saburral Fever.—Febris Pituitosa; Febris Gas- trica; Febris Intestinalis; Febris Mesenterica. Between the simple autumnal remittent and intermittent fe- vers, there exists no essential or radical difference. They are pro- duced by the same cause, and differ .from each other only in the grade of violence and duration of the paroxysms. As remittents, however, assume a peculiar character, in relation both to their ge- neral phenomena and their course, and demand a treatment corre- spondingly modified, they are properly made a subject of distinct consideration, although some writers, following a different course, treat of them under the same general head. Sympt07ns.—The symptoms which occur in the forming stage of remittents, do not differ from those which usher in the intermit- tent paroxysm. Languor, drowsiness, a sense of anxiety, aching REMITTING FEVER. 129 pains in the back, head and extremities, are the prominent symp- toms of its initial stage. Slight chills are, however, often among the very first manifestations of indisposition—at first, they alternate, with flushes of heat, which latter gradually increase in duration until they predominate wholly, and the febrile reaction is fully developed. When the fever is once completely established, the pains in the head, back, and lower extremities, become greatly aggravated. These pains, especially those seated in the back and legs, are sometimes so severe, as to resemble in violence, those which occur in acute rheumatism. The eyes soon acquire an icterode or yellowish tinge; the tongue becomes covered with a brownish fur; nausea, and occa- sionally bilious vomiting occur; a sense of fulness and weight or ten- sion is felt in the right hypochondrium, and epigastric regions; respi- ration is more or less oppressed and anxious; the urine is scanty and deeply tinged with bile; the pulse is full, frequent, but seldom very hard or tense, and the skin is generally dry and hot. These symp- toms continue until the succeeding morning, when a gentle perspi- ration appears on the superior portions of the body, and sometimes over the whole surface. The febrile excitement now abates, fre- quently, very considerably; but not so as to amount to a state of apyrexia—the skin still remaining preternaturally warm, and the pulse irritated. This remission continues but a short time—not more, commonly, than from one to two hours. The febrile excite- ment rises again with more or less celerity, until it acquires its former violence, or, perhaps, exceeds it; which, after a certain period, again abates, and gives place to another remission. In this way the fever proceeds, undergoing regular revolutions of exacerbations and remis- sions, until it either finally terminates in a perfect crisis and con- valescence, or assumes a more uniform or continued course. This description answers for the simple and usual form of the disease, as it occurs in the autumnal months of the temperate latitudes; or, for the milder remittents of the warmer climates. There is, however, no form of fever which is subject to so great a diversity, in relatjon to its grade of violence, as the present one. In the intertropical re- gions, it usually assumes the most fatal and violent character; and at almost every place where it is endemial, it is attended with circum- stances which give it a somewhat peculiar character. It is, indeed, impossible to give any description of this disease, which can have more than a very general application. We must content ourselves with a delineation of the prominent and characteristic outlines of its physiognomy, (if I may be allowed the expression;) and with a detail of those phenomena and circumstances, which may be deemed essen- tial, and which have a particular bearing upon its remediate manage- ment. The ordinary mild remittents of this climate, generally assume the double tertian or quotidian type; but the former type is by far the most common; for, although the exacerbations occur once every day, yet, we almost always find a very manifest aggravation of all the Vol. 1.—17 130 REMITTING FEVER. symptoms on the odd or alternate days. The exacerbations of a remittent of the quotidian type generally occur several hours earlier than those of the double tertian type—the former happening usually about nine or ten o'clock, and the latter not till towards noon, or an hour or two later. The remissions which so generally occur in the violence of the symptoms of this form of miasmal disease, are not, however, always so considerable as to be readily perceived, either by the patient or the physician; and, in some instances of an aggravated character, they may be, for a time, altogether inconspicuous or absent. It must be observed, moreover, that they do not invariably occur in the morning or forenoon; on the contrary, instances are met with where the remissions take place in the evening or at some period during the night. Remittents, although mild and regular in their commencement, are apt to assume an aggravated and dangerous character, if they continue unchecked beyond the ninth day, or second week. When this happens, the tongue becomes more and more loaded with a brown far, and dry along the middle; .delirium occurs more fre- quently and strongly; the skin acquires a deeper tinge of yellow, and a greater intensity of heat during the exacerbation; debility becomes more and more conspicuous, and the bowels distended with flatus, and tender to external pressure; and, finally, in many cases, watery and offensive discharges from the bowels, retention of urjne, continued vigilance, restlessness, and almost constant delirium. In the paludal districts of hot climates, remittents rarely occur in the mild and simple form which they are wont to assume in the temperate latitudes. They generally acquire a highly aggravated and dangerous character; and under circumstances particularly favourable to their occurrence, they are apt to assume a high degree of malignity from their very commencement. Remittents of this violent grade generally make their attacks suddenly, and with great impetuosity. The cold stage is short and not often very severe. The febrile heat soon predominates and rises rapidly to a state of great intensity—and is attended with tormenting thirst, violent headach, excruciating pains in the loins and the inferior extremities, great anxiety of feeling and difficulty of breathing, with nausea, and a distressing sense of weight and fulness in the stomach. These symptoms continue for about twenty-four hours, when a remission, always very considerable, and frequently amounting almost to a perfect intermission, takes place. This calm, however, is but tran- sient. A second paroxysm soon ensues, more violent and alarming than the first. The eyes now become yellow, watery, and red; the oppression and anxiety in the epigastrium is extremely distressing, and a deadly sickness, with constant vomiting or retching, torments the patient. After the lapse of some time, these violent symptoms again abato, and a clammy perspiration appears on the surface of the body. During the two first paroxysms, the bowels are, generally, REMITTING FEVER. 131 torpid. In this way, the paroxysms continue to recur, until either a salutary crisis or death takes place, one or the other of which not unfrequently happens in the third paroxysm. If the disease runs on beyond the fifth or sixth paroxysm, very great prostration ensues; the remissions become less distinct; delirium almost constantly attends; and the skin acquires either that peculiar stinging heat, called calor mordax, or becomes cool and cadaverous to the touch. The pulse, in cases of this kind, frequently differs but little from its natural state; more commonly, however, it becomes quick, irregular, and frequent. In this aggravated and protracted state of the disease, various other symptoms usually occur, in addition to those already mentioned, indicative of the fatal malignity of the malady. The lips become swollen, and of a livid or purple hue; the tongue dark brown, or black—fetid and clammy; the eyes red and watery, or quite dry; the urine dark brown, offensive, or entirely suppressed; the alvine discharges reddish and watery, or black, bloody, or col- liquative, attended generally with a tympanitic state of the abdomen; and petechia and haemorrhages occasionally occur in the last stage of the disease. In general, the violence of the disease will be in proportion to the suddenness and vehemence of the incursion. When the attack approaches gradually, with the ordinary premonitory symptoms mentioned above, the disease usually runs its course slowly. When, on the contrary, the invasion is sudden and violent, we may expect the disease to be rapid and violent in its progress. The first pa- roxysm only is usually ushered in by a very distinct cold stage —the succeeding exacerbations being rarely preceded by a sense of chilliness. Between the mildest variety of the disease, and the rapid, vehe- ment and fatal variety just described, this form of fever appears under the greatest diversity of grades, and general character. Re- mitting, like all other forms of general fever, is liable to become complicated, either at an early or late period of its course, with local inflammations; and these secondary local affections constitute the chief and most important cause of those remarkable diversities which are known to occur in this disease, in different localities, or at the same place in different seasons. From some inexplicable circumstance, connected, apparently, with the peculiar concentra- tion or character of the miasmata, we find that in certain localities and seasons the disease manifests a peculiar tendency to fall, with es- pecial violence, on some one organ or structure, as the brain, the liver, the alimentary canal, or the blood-vessels, and to assume, in consequence, a peculiar character in relation to its general phenomena and degree of fatality. In general, however, two important organs—the liver and the alimentary canal, are the parts most apt to become prominently affected in fevers of this kind. In relation to these affections, two distinct modifications of the disease occur; one, in which the phe- 132 REMITTING FEVER. nomena of gastro-enteritic disorder are especially prominent; and another modification, in which predominant hepatic derangement impresses its peculiar stamp or character on the disease. To the former, the term gastric, and to the latter that of hepatic, might, not unaptly, be applied. The remittents of the former variety, namely, gastric remittents, are characterized by the following phenomena, viz: redundancy of vitiated bile in the stomach and bowels; a bitter taste; a thick yellowish layer of mucus oh the tongue, becoming dry, cracked, and of a dark brown or black cojour in the progress of the disease; total loss of appetite, and sometimes extreme disgust for every kind of food; a turbid, yellowish, or jumentose urine; great weight and anxiety in the prascordia; bowels tender on external pressure, and distended with flatus; great pain in the loins and knees; intense pain in the forehead; very distinct remissions; a red or fiery edge and tip of the tongue; or after the brown and black crust scales off, a smooth, shining, and red surface of the tongue; watery and red- dish stools, resembling the washings of flesh; retention of the urine; difficulty of swallowing liquids in the advanced stage; great craving for cool and acidulated drinks, &c. Those remittents which manifest predominant hepatic disorder, that is, hepatic remittents, are characterized by intense febrile heat? violent pains in the head, and early delirium; fulness and tension in the right hypochondrium, with pain and pulsation in the epigastrium and right hypochondrium; a clean tongue, at first; excessive irrita- bility of the stomach; frequent and forcible vomiting, without the ejection of any bile, the matter brought up consisting of a glairy fluid, mixed with the drinks that may have been received into the stomach; great torpor of the bowels; a very yellow tinge of the skin; and tunica albuginia; and towards the determination of the disease, a copious discharge from the bowels of a dark or pitch-like matter. In this variety of the disease, the liver is manifestly inac- tive, and in a state of great sanguineous congestion. That this is the case, may be inferred from the absence of bile in the ejections from the stomach; the clean tongue; the sense of weight, fulness, and pulsation in the right hypochondrium; the great torpor of the bow- els; the intensely yellow colour of the skin; and the excessive and continued retching and vomiting. This latter symptom, namely, extreme irritability of the stomach, may be regarded as a strong manifestation of sanguineous engorgement and functional inac- tivity of the liver. We find this pathological fact exemplified in cholera, particulary in cholera infantum, in which disease there is seldom any bile whatever discharged during its early period; and the appearance of this secretion in the discharges may be hailed as a very favourable occurrence. Towards the conclusion of this variety of remittent fever, the liver frequently recovers its action and re- lieves itself by pouring a large quantity of black bile, or perhaps blood, into the bowels, as is manifested by the copious, dark-coloured REMITTING FEVER. 133 or tar-like alvine discharges, which usually occur in such cases. These large and very peculiar discharges may, indeed, be regarded as the favourable crises of such fevers; for convalescence generally soon follows their appearance; and except the disease be arrested by remediate treatment in the early period of its course, there are but few recoveries in which such discharges do not occur. Dr. Cart- wright describes an epidemic fever, which prevailed in Monroe county, Mississippi, in the autumn of 1822, which was strikingly marked by the characteristic phenomena of this variety of fever. "The disease," he says, "was generally ushered in by a distinct chill, which was speedily followed by intense heat, thirst, and head- ach, and very severe pains in the loins. The anxiety and difficulty of breathing, the deadly sickness, sense of weight, heaviness, and pain in the stomach,increased as the fever approached its acme,until the suf- fering became intolerable. The exacerbations generally occured in the evening, and a considerable remission, amounting in some cases to a perfect intermission, took place on the ensuing morning. On the even- ing of the second day a sudden and unexpected paroxysm, more vio- lent than the first one, came on, which was attended with a most horrid sensation of pain and oppression of the stomach, accompanied with deadly sickness and continued vomiting, but with the ejection of very little fluid of any kind. The bowels, during the first and second paroxysms, were always in a state of obstinate constipation. About noon of the third day the third paroxysm generally came on. During this paroxysm the skin usually felt rather cooler than natu- ral, and the pulse was commonly remarkably slow. By placing the hand on the abdomen, a pulsation was felt equal to that which the heart produces in the thorax, and synchronous with tbe*pulsations of that organ." During the first two paroxysms the tongue was but little furred; but in the third it assumed a much worse appearance, having a dark red line running from its extremity over its dorsum, which soon changed to a black colour. The skin began to acquire a yellow colour during the third paroxysm. The paroxysms con- tinued to recur until the fifth, seventh, or ninth day, when either death took place, or "enormous dark coloured evacuations from the bowels occurred, and the patient commenced to convalesce."* Although the symptoms just mentioned clearly indicate very prominent disorder of the liver, it is equally evident, that in these cases, the mucous membrane of the stomach and bowels is always, perhaps, in a state of considerable irritation, and probably often of inflammation. Nevertheless, it can scarcely be doubted that the pe- culiar phenomena of this variety of the disease, and which distinguish it from other modifications of remitting fever, depend mainly on certain morbid conditions of the biliary organs, and which do not occur to the same extent in other varieties of the disease. More or less derangement of the biliary system, appears, indeed, to be a uni- * Medical Recorder, vol. vi. 134 REMITTING FEVER. versal attendant on remitting fever. The tendency of miasmata to act upon and disorder the liver, has already been particularly men- tioned; and it may be presumed from this circumstance, independent of the phenomena of the disease, that prominent functional disorder of the liver, constitutes one of the most constant local affections of remitting fever. Before I leave this part of the present subject, it may be useful to advert again to the former or gastric modification of this disease, and to direct the attention of the reader more particularly to the great tendency there exists in remittents, when they are prolonged in their course, to the occurrence of a high grade of irritation or subacute in- flammation of the mucous membrane of the intestinal canal. In most cases of protracted remittents, even of the mildest kinds, the abdo- men becomes somewhat tympanitic, and tender to external pressure; and the character of the stools, which are often found to resemble the washings of flesh, are a further evidence of such a condition of the bowels. In a practical point of view, it is of the utmost conse- quence to be aware of this circumstance; for in many instances this secondary inflammation is excited by the too frequent employment of irritating purgatives, and the disease greatly aggravated and pro- tracted by such a course of treatment. In localities where miasmata are copiously generated, or possess great virulency, remitting fever sometimes comes on under symp- toms of cerebral disorder, simulating apoplexy or mental derange- ment. In Italy, and the intertropical countries, the disease, not un- frequently, makes its attack under one or the other of these cerebral affections. Sudden and furious mania is sometimes among the first manifestatio«s of the disease; and many patients sink, at once, into a state of insensibility and apoplectic oppression, from the vehement action of the miasmata on the brain. The brain, however, is not so apt to suffer inflammation in this form of fever, as in those which are the \>rod\xo.tot idio-miasmata, contagion, or atmospheric vicissi- tudes. This, at least, may be affirmed of the ordinary remittents of the middle latitudes; and it is probably generally correct in refer- ence to all malarious fevers. Nevertheless, when the mucous mem- brane of the alimentary canal becomes inflamed, the brain usually manifests strong sympathetic irritation, by more or less violent deli- rium of nearly uninterrupted continuance. It is, perhaps, on this account, namely: the comparative infrequency of cerebral inflam- mation in remittents, that we do not so often observe that sudden and remarkable collapse of the vital energies in this disease, as in the fevers produced by other causes. The ordinary remittents of the temperate latitudes often termi- nate in intermitting fever before the final disappearance of the dis- ease; and it is not uncommon for the milder varieties of the disease to assume the intermittent form at an early period of their course. This conversion of form appears to be particularly favoured by blood- letting practised during the first few days of the fever. Remittents REMITTING FEVER. 135 also, frequently terminate in other affections; such as neuralgia; chorea; paralysis; diminution of the powers of intellect; organic disorder of the liver and spleen; dropsy; pain and swelling of the large joints, &c. Causes.—After what has been already said under the heads of koino miasmata and intermitting fever, in relation to this subject it will be sufficient to observe, that besides koino-miasmata, which are unquestionably the sole epidemic source of this form of fever, there are a variety of other causes capable of producing this malady. Worms and other irritating substances lodged in the bowels, may give rise to a regularly remitting form of fever. The disease known under the term of "infantile remittent," appears to arise from intes- tinal irritation. In the remitting fevers produced by causes of this kind, however, the biliary organs are much less apt to become impli- cated than they almost invariably are in the miasmatic remittents. Whatever may be the remote cause of remitting fever, however, it seems very evident that the principal morbid irritation is always lo- cated in the abdominal organs, and more especially in the liver and mucous membrane of the alimentary canal. So unequivocal and uni- versal is this gastric disorder or irritation, that some eminent physi- cians have, in consequence of it, designated the disease by the name of gastric fever. (Ritcher.) Indeed, this term appears to me preferable to that of remittent, which has no reference to the pathological condition of the system, and might, with equal propriety, be applied to hectic fever, which, though very distinct from remitting fever, has remissions and exa- cerbations almost as conspicuous and regular as that disease. Treatment.—The principal indications to be fulfilled in the treat- ment of remitting fever are: 1, to moderate the febrile reaction of the arterial system; 2, to remove out of the alimentary canal the vitiated and irritating secretions which may be lodged in it; and 3, to obviate gestro-intestinal irritation, and restore the healthy functions of the liver, and alimentary tube. I shall speak in the first place of the treatment proper in the milder or gastric variety of the disease. With regard to the first of these indications, very discrepant senti- ments have been expressed as to the particular means best calculated for its fulfilment. Some recommend a prompt and free employment of the lancet as decidedly beneficial in the treatment of remittents, whilst others admit its occasional utility, and others, again, repre- sent it as frequently injurious, and rarely beneficial. In the ordi- nary autumnal intermittents of this climate, blood-letting, I am well satisfied, may be often, very properly, entirely omitted. The pulse in the milder cases of this disease, particulary where the intestinal canal is loaded with bilious and other saburral matter, is not often sufficiently hard and tense to warrant copious or repeated abstrac- tions of blood. In such cases, when unaccompanied by symptoms of strong local congestions or visceral inflammation, I have not found it necessary to draw blood. There can be no doubt, however, that 136 REMITTING FEVER. in particular localities, and under peculiar circumstances of atmo- spheric constitution and vicissitudes, remitting fevers may sometimes assume a character which demands the free use of the lancet. To condemn the use of the lancet universally, would be as erroneous as to enjoin its invariable employment. Bleeding cannot be employed or withheld, merely on the ground that we are prescribing for a particular disease. In all maladies, the state of the pulse must be our main guide, in relation to the use of the lancet. When the pulse is either hard or tense, whether it be full or contracted, blood may be safely, advantageously drawn, whatever may be the name, or the general character of the disease. In cases that are attended with violent pains in the head—a full, vigorous, and hard pulse, with a very hot and dry skin, bleeding is, unquestionably, decidedly indicated, and ought not to be neglected. Having moderated the momentum of the circulation by venesection, where this measure is indicated, the attention should next be directed to the alimentary canal. Considerable discrepancy of opinion has been expressed, in relation to the employment of emetics in the treatment of remitting fever. In the ordinary autumnal remittents of the temperate climates, gentle emetics will often afford some ad- vantage; but their usefulness is, probably, much too highly estimated, by the majority of those who are in the habit of employing them in this disease. I have of late years but rarely resorted to them in this form of fever, and I am inclined to think, that they may be generally well dispensed with, without losing any peculiar remediate advan- tages. There exists a decided tendency to gastro-intestinal irrita- tion in every modification of this disease; and, although the operation of an emetic may procure temporary benefit, yet some risk will be incurred of its exciting a degree of permanent irritation, which will subsequently exercise a most pernicious influence upon the pheno- mena and progress of the disease. In the year 1822,1 attended a con- siderable number of patients labouring under the milder form of remit- ting jever. During the early part of the season, I prescribed an emetic in the majority of cases that came under my care. In many of these cases, a great degree of gastric irritability continued to prevail dur- ing the first period of the malady, and in the advanced stages, much tenderness and tympanitic tumefaction of the abdomen supervened. The disease, in these instances, was wont to run a tedious course— the abdomen became sore to pressure, and the alvine discharges often became watery, reddish, and painful—in short, unequivocal manifest- ations of high irritation or phlogosis of the intestinal mucous mem- brane often supervened. Towards the middle period of the season I left off employing emetics entirely; and, with the exception of one or two brisk cathartics, in the commencement, confined myself to the use of the milder laxatives, to keep up the requisite discharges from the bowels. From this time on, I met with but few cases in which the former unfavourable symptoms occurred. It must be confessed, however, that there are very respectable authorities to be REMITTING FEVER. 137 adduced in favour of the use of emetics, not only in the mild, but even in the more rapid and violent varieties of this form of fever. Whatever doubts may be entertained in relation to the usefulness of emetics in the ordinary forms of remitting fever, the weight of good testimony is decidedly against their employment in those violent grades of the disease which occur in hot climates, and in which there exists, generally, the utmost degree of gastric irritability. That emetics may sometimes be administered without detriment, and even with benefit in these vehement and dangerous varieties of the disease, may be admitted; but it is most obvious, that no small degree of danger must be incurred from the impressions of such a remedy upon the delicate and already irritated or highly irritable mucous membrane of the stomach. The foregoing observations apply with still greater propriety to the employment of what are termed emeto-cathartics. Chisholm speaks favourably of their em- ployment; but there have been, comparatively, few practitioners who appear to have found them beneficial. I do not doubt, that in the milder cases, the conjoined operation of an emetic and a purge, will occasionally make a favourable impression on the disease; but I am equally satisfied, that much injury may result from the irritation which they are calculated to produce. In relation to this subject, Dr. Heustis, of Alabama, whose opinions are entitled to much respect, makes the following observations. "As far as my observation ex- tends, I think I am warranted in saying that tartar emetic can never be prudently exhibited in the high and malignant grades of bilious fever. I am confirmed in this opinion from having seen and known so many instances of alarming, and sometimes fatal prostration pro- duced by its exhibition; I have known a person in a high fever, with a strong and full pulse, and generally increased temperature of the body, in less than two hours after taking this poisonous medi- cine to be affected with a death-like coldness; the pulse at the wrist no longer perceptible, the eye inanimate, the lips, cheeks and ex- tremities exhibiting the lividity of death, a cold and copious sweat exuding from the general surface of the body, and every symptom of approaching dissolution. Frequent occurrences of this nature, have for the last two years, almost entirely banished the use of tartar emetic from my practice; nor do I ever exhibit it except in the inter- mitting form of fever, or mild cases of remittents, and even in these instances experience has proved that its exhibition is unsafe, except in the recess or remission of the fever."* Whatever may be thought of the propriety of administering eme- tics or emeto-cathartics in this disease, almost universal experi- ence speaks decidedly in favour of the employment of purgatives, not only in the beginning, but at proper intervals throughout the whole course of the disease. In all instances where the irritatibility of the stomach does not forbid the administration of a purge, the * The Amer. Jour, of the Med. Sciences, vol. ii. p. 40. Vol. I.—18. 138 REMITTING FEVER. bowels should be early and thoroughly evacuated by a suitable purga- tive. A combination of calomel and jalap, in the proportion of ten grains of each, will, in general, suffice to procure adequate evacua- tions. Having emptied the bowels well, by a brisk cathartic in the onset of the disease, recourse must next be had to such remedies as are calculated to restore the healthy functions of the liver, alimentary canal, and skin, and to moderate the general febrile excitement, and obviate or remove the local congestions op inflammations that may supervene. To correct the morbid condition of the liver, skin, and alimentary canal, constitutes the chief part of the treatment of this malady. For this purpose, the following combination will often answer ex- tremely well: R.—Pulv. nitraf. potassae jjj. Pulv. ipecac. Calomel aa gr. xii.—M. ft. Divide into six equal parts. One of these powders is to be taken every two or three hours. The substitution of the ipecacuanha for the usual ingredient, tartar emetic, will obviate the tendency of this mixture to irritate the bow- els, and to cause frequent and griping watery stools—which rarely fail to aggravate the violence of the disease. Calomel is a most im portant remedy in this form of fever. Its power of altering the mor- bid condition of the liver, and of the whole capillary system, to- gether with its gentle aperient effects on the bowels, renders it peculiarly calculated to do good in this disease. To obtain these important advantages, the calomel should be early and regularly ad- ministered, and continued until slight manifestations of its specific influence on the system may be noticed in the gums. When this occurs, its use must be suspended. For more than fifteen years I have employed this remedy in nearly every case of remitting fever which has come under my management, where I have been called to the patient during the first two or three days of the disease. In a great majority of these cases, I found all the symptoms of the dis- ease to abate, often very considerably, as soon as the mercurial influ- ence became conspicuous; and in many instances, a speedy conva- lescence ensued. Although a very gentle mercurial impression is generally decidedly beneficial in this malady, yet strong mercuriali- zation or ptyalism, appears to be generally detrimental—at least in the ordinary remittents of this climate. It is to be observed, more- over, that in the advanced periods of the disease, the constitutional operation of mercury will be much mqre apt to prove injurious than beneficial. In general, the salutary influence of mercury is restricted to the first five or six days of the disease; and the earlier its general operation can be procured, the more certainly will it prove ad- vantageous. When the above combination of calomel, nitre, and ipecacuanha excites active purging, as has sometimes been the case, we may not REMITTING FEVER. 139 only lose the specific influence of the mercurial, but there is danger of superinducing inordinate irritation in the mucous membrane of the intestinal tube. Whenever frequent painful and watery stools follow the exhibition of the above combination, the nitre ought to be left out, and ipecacuanha or small doses of Dover's powder added to the calomel. Throughout the whole course of this disease, a gen- tle and regular action of the bowels ought to be carefully promoted by mild laxatives; but, excepting in the very commencement, strong and irritating cathartics, especially when frequently administered, are frequently prejudicial. There is no class of remedies which is more indispensable in the treatment of remitting fevers than laxa- tives; and yet, there are no medicinal agents which are so frequently abused, or improperly employed in this disease, as this very class of evacuants. Violent and irritating cathartics, when repeatedly ad- ministered in this form of fever, seldom fail to induce a state of irri- tation in the mucous membrane of the bowels, from which a train of distressing and dangerous consequences arise in the advanced stages of the malady, which are often of more serious import than the original disease itself. The thin, watery, muddy, reddish and fetid stools—the tympanitic and tender state of the abdomen—and the cerebral irritation which frequently occur in the latter period of the disease, are very often the results of the frequent use of active and irritating cathartics in its treatment. "There is one fault which a physician sometimes commits in the treatment of bilious remit- tent fevers, and that, too, for the most part, when he thinks he is do- ing right. I allude to the too long continuation of purgative medi- cines. He is apt to think that the impurities have been long fixed in the bowels, and, in order to cleanse his patient thoroughly, and to leave nothing noxious behind, he persists in the use of purga- tives. What is worse, every appearance of these cases would seem to justify his suspicion of the existence of fixed impurities of long standing in the bowels, and confirms him in his design of at once, and for all, making a clean house. The longer he continues to give his purgatives, the fouler does the tongue become, and the more dis- tressed the stomach; the symptoms, in short, of intestinal impurities become more and more conspicuous, whilst he continues to dilute and to evacuate, without reflecting or knowing that he is himself the cause of all the noxious matter in the intestines, by constantly irritating them with his purgatives, and keeping up an afflux of flu- ids to the internal or villous coat. The most healthy individual will get a foul tongue and lose his appetite, if he take neutral purgative salts for several days in succession."* Although frequent and harsh purgation is generally decidedly detrimental in the treatment of this form of fever, yet the total pro- scription of laxatives from the list of remediate agents suitable for * Medical and Surgical Observations, p. 120. 140 REMITTING FEVER. its cure, is no less calculated to favour injurious consequences. There is always an abundance of vitiated bile and other morbid secretions poured into the bowels in this disease; and the generation of acrid and irritating materials by putrefactive and fermentative decompo- sition in the bowels, soon adds greatly to these sources of intestinal irritation, if the bowels be not, lrom time to time, gently evacuated by laxatives. Mere purgative enemata and bland diluents are wholly inadequate to remove these permanent irritants from the bowels, or blunt their activity. The irritation which such intestinal impurities create, must be vastly more intense and protracted, than the trifling and transient irritation of a laxative administered for their expulsion. In the commencement of the fever we may em- ploy one or two active purges, viz: Be.—P. Jalap. Calomel aa gr. xii. 0r' ijfc.—Extract, colocynth. comp. gr. xii. Calomel gr. x.—M. Divide into four pills, to be taken at one dose. Or, R.—Calomel.... gr.x—To be followed with one ounce of sulphate of soda, in three hours after the calomel is taken. After the first, or, at most, the second thorough purgation, the mildest laxatives, assisted with acidulated diluents, ought alone to be employed for evacuating the bowels; such as the Seidlitz pow- ders; small portions of Epsom salts, preceded by a few grains of calomel; castor oil, with a few drops of laudanum; a mixture formed of magnesia, castor oil, and lemon syrup, constitutes an elegant, plea- sant, and gentle laxative, which I have often used with very excellent effects. It is made by mixing very intimately in a mortar an ounce of the oil with a drachm of carbonate of magnesia, and then adding and mixing with it, about an ounce of any of the usual syrups. Of this a large table-spoonful is to be taken every hour, until the bowels are moved. From two to three evacuations ought to be procured every twenty-four hours during the whole course of the disease. Much of the treatment of fevers of this kind depends on the judi- cious management of purgatives. Circumstances may indeed occur, which will render the employment of an active purge peculiarly beneficial even in the latter periods of the disease. This is particu- larly apt to occur in those violent cases in which the liver at last pours out large quantities of black bile, and which, if not speedily removed, may cause a prostration or oppression of the system by exciting a state of general nervous irritation. Along with the reme- dies already mentioned, some advantage may be obtained, from the usual antiphlogistic diaphoretics—such as the effervescing saline mixture, the spiritus mindereri, and the free use of bland acidulated drinks. The following mixture will be found a decidedly useful REMITTING FEVER. 141 remedy in cases attended with much restlessness, anxiety, and a hot and dry skin, where there is no particular determination to, or excite- ment of the brain, and the febrile reaction is not very violent.* R.—Liquor ammoniae acetat. §vjj. Spir. nit. dulc. 3jj. Tinct. opii. acetat. gtt. 30.—M. ft. Of this a table-spoonful may be taken every three hours. Nitre with small portions of tart, antimony, dissolved in a bland mucilaginous fluid, will, in general, assist considerably in reducing the febrile heat, and promoting diaphoresis. We may also employ a solution of the muriate of ammonia, with much advantage, ac- cording to the formula given at page 127 of this volume. Indeed, this article, administered in the manner directed by this formula, appears to me better calculated to do good in bilious remittents than nitre. It should be particularly observed, however, that both these remedies, more especially nitre, cannot be properly employed in cases attended with much gastric irritability, or gastro-enteric irritation. When the skin is very hot and dry, during the exacerbations, the sufferings of the patient may be much alleviated by sponging the body with cool water, and suffering it to evaporate by the heat of the body. The use of mild, cool and acidulated beverages, ought to be en- joined as an important item in the treatment of this disease. Inde- pendent of the effects which drinks of this kind have in blunting the acrimony of the fluids lodged in the alimentary canal, they usually exert a soothing antiphlogistic influence upon the system, and they may do much good, moreover, by supplying the intestinal absorbents with a fresh and wholesome fluid, and thereby preventing or lessening the absorption of irritating or vitiated matters from the bowels. Drinks made with lemon or citric acid and sugar, are, perhaps, the best diluents for this purpose. Barley-water, acidulated with lemon juice; warm water poured on sliced apples, and after- wards suffered to cool,—fresh orange juice diluted with cool water, or currant jelly mixed with water, are grateful and salutary beverages. When, either from the imprudent employment of irritating purges, or from other causes, the mucous membrane of the intestinal canal is brought into a state of high irritation or sub-acute inflamma- tion, the disease generally loses its remittent form, and often assumes a low typhoid character, with almost constant delirium, a tender and tympanitic state of the abdomen, a dry, dark brown, or black crust on the tongue, with clean red edges; watery and reddish stools; great prostration; and a very dry and hot skin. Cases of this kind fre- quently run on for several weeks; and convalescence is always very gradual and tedious. When the fever assumes this aspect, our * Dr. Agnew on the late epidemic, intermittent, and remittent fever at Harris- burg. Vide Medical Recorder, vol. vi. p. 147. 142 REMITTING FEVER. remediate measures must be chiefly directed against the intestinal phlogosis. Leeching the abdomen will often afford much benefit; and it ought never to be neglected where leeches can be had. A large emollient poultice will assist, very materially, in reducing the intestinal affection. I am perfectly satisfied that we may, in general, derive much more good from applications of this kind than from blistering. Fomentations with flannel wrung out of hot water, will answer the same purpose; but this mode of fomenting is more trouble- some, much more variable in its impressions, than the application of warmth and moisture by means of a poultice, and probably not more efficacious. Internally I have exhibited small doses of calomel and opium in such cases with manifest advantage. The one-sixth of a grain of the former with a quarter of a grain of the latter may be given every two or three hours. The bowels must be kept open by laxative enemata, and the patient requested to take freely of some bland mucilaginous fluids—such as barley water, very thin oat-meal gruel, or gum arabic dissolved in water. No other articles of food must be allowed, on any account. In such cases, I have thought that considerable benefit was derived from epispastics on the legs just above the ankles. This measure is particularly useful when the extremities are cool, while the skin of the body is hot—a circumstance which is not uncommon in instances of this kind. An emulsion of balsam copaiva also will frequently procure consider- able advantage. I have so often seen the most decided benefit derived from this article, in protracted cases, attended with great irri- tation, or subacute inflammation of the bowels, that I should consider myself as neglecting an important curative means, were I to omit prescribing it in diseases of this character. It may be given thus: R.—Bals. copaiv. ^ss. Sacch. albi. §ss. Pulv. gum arab. gjj. Misce. dein adde. Aq. fontanae gjj.—M. ft. Take a spoonful every two hours. Although very considerable prostration often occurs in such cases, stimulants or tonics are by no means admissible, anterior to the period of convalescence. Hitherto I have spoken only of the simple, or less violent variety of remitting fever—of those remittents which occur in the temperate latitudes, and which, though sometimes both violent and rapid in their progress, do not assume that high and dangerous grade of febrile action which is so common and so fatal in hot climates. In the higher and maligant forms of remitting fever, a treatment somewhat different from the one I have just detailed, is requisite. In these aggravated states of bilious remitting fever, the liver is deeply implicated, and the stomach is generally extremely irritable. Here, therefore, we cannot commence as we may in the simpler forms, with emetics, or emeto-cathartics, and often not even with a purga- REMITTING FEVER. 143 tive. Instead of irritating the stomach by medicines of this kind, our first object, often, must be to allay the excessive gastric irrita- bility, in order to enable the patient to retain the remedies which his case may demand. Among the means which experience has shown best calculated to effect this purpose, blood-letting holds, perhaps, the first rank, where the arterial reaction is vehement To be bene- ficial in this respect, h'owever, it must be early and copious. I have known excessive irritability of the stomach and retching promptly checked, in the onset of the disease, by one efficient bleeding. Sinapisms over the epigastrium will sometimes aid considerably to moderate the excessive gastric irritability, but applications of this kind cannot be generally used with propriety until the reaction of the heart and arteries has been, in some degree, moderated by venesec- tion. A draught of cold water is not only extremely grateful, but, when the skin is hot and dry, often very beneficial in restraining excessive vomiting in cases of this kind. The saline effervescing draught, artificial mineral water, (carbonated water,) the warm bath, lime water and sweet milk, spiritus mindereri, have all been recom- mended and used for this purpose. Sinapisms laid on the calves of the legs will sometimes speedily diminish the morbid irritability of the stomach, in cases of this kind. I have just stated that blood-letting is one of the best, if not the most effectual means for allaying the extreme irritability of the stomach, which is apt to occur in the violent grades of this disease. This observation applies, however, to such cases only as are attended with high vascular reaction, for where the vital energies are pros- trated, this evacuation is of course inadmissible. Having allayed the gastric irritability where it was excessive, our principal reliance must be placed in the judicious employment of calomel. The liver, in this violent grade of the disease, is generally congested, torpid, or otherwise deranged to a very great degree; and our remediate efforts must, therefore, be particularly directed to this viscus. Ex- perience, indeed, has fully demonstrated the excellent effects of calo- mel in this affection. There are some practitioners, it is true, of great respectability, who do not approve of the free employment of mercury in this disease; but by far the largest proportion of those who have practised in warm climates—particularly of the American and British practitioners, have given their decided testimony in favour of the mercurial treatment of the higher grades of miasmal fevers. In no country in the world, perhaps, is calomel so freely employed in the treatment of this malady as in the southern sections of the United States. The almost unanimous testimony of our southern physicians (many of whom are deservedly held in high estimation for their talents and medical acquirements,) in favour of this practice, will scarcely permit us to doubt of its general useful- ness. The American practitioner, free from the trammels of sys- tems, and the dogmas of the schools, pays no further regard to the verba magistri than is sanctioned by his own experience and obser- 144 REMITTING FEVER. vations. He inquires, observes, and reflects for himself, and adopts that mode of treatment which he finds, from varied experience, most successful. A practice, which has received the approbation of a numerous portion of the profession, may be confidently regarded as founded on individual experience and observation, and not adopted on mere authority, and entitled, therefore, to full confidence. As it is of the utmost consequence to make an early and decided mercurial impression on the system, the calomel ought to be given in large and frequent doses. From ten to twenty grains should be administered every four or five hours, until the gums begin to show its influence, or until the evacuations become conspicuously bilious. While we thus endeavour to produce a general mercurial action, and especially to restore the regular functions of the biliary organs, the bowels should be kept freely moved by additional aperients, if the calomel do not produce this effect by itself. If the bowels be not freely evacuated by the two first doses of calomel, an additional purgative ought to be administered. For this purpose, an ounce of the sulphate of soda, or of magnesia; or from fifteen to twenty grains of the compound extract of colocynth; or a dose of calomel and jalap, will generally answer well. In general, however, very active purges will be less beneficial or proper than the milder ones. Indeed, so long as the liver remains inactive and engorged, it will rarely be advisable to repeat even the purgatives I have mentioned. After the first efficient mild purge, it will generally be much the best plan to keep the bowels open by laxative enemata, and the use of tama- rind water, or the Seidlitz powders, if these can be had. When the liver begins to act, and to pour its dark bile into the bowels, however, laxatives of a more active character become indispensable. In cases attended with a distressing sense of sickness, accompanied with soreness in the epigastrium, leeching, succeeded by a large blister over this region, will often afford much relief. Experience does not, however, offer much in favour of the employment of blisters as a general remedy, either in this or the more mild variety of the disease. Little or no advantage is to be obtained from the ordinaryT dia- phoretic remedies in the higher grades of the disease. Nitre, indeed, and the antimonial preparations are wholly out of the question where there is much gastric irritability. Where the stomach will bear it, James's powder, in small doses, with calomel, may often be advan- tageously employed. The saline effervescing draught, and the spirit- us mindereri, will sometimes aid in allaying the sickness of the stomach, and removing the torpor of the cutaneous exhalents. In all instances, perhaps, the enjoyment of cool acidulated drinks- such as lemonade, thin barley water, with a little fresh lemon juice, ought to be freely allowed. Tamarind water also is an excellent beverage in cases of this kind, on account particularly of its aperient properties. Drinks of this kind tend to moderate the intense febrile heat, and they do good, moreover, by diluting and obtunding the REMITTING FEVER. 145 acrimony of the vitiated fluids, which are almost continually gene- rated in the alimentary canal. The propriety of employing tonics during the remissions of the disease is a point which has been very variously represented by different writers. Lind, Clark, Balfour, and a host of others contend zealously for the vigorous exhibition of bark as soon as a considerable remission occurs in the disease. Dr. James Johnson, on the contrary, with a number of other late writers on this disease, condemns this practice in terms of unqualified reprobation. Dr. Burnet, in his Essay on the Bilious Remittents along the Mediterranean, asserts that under "the use of the cinchona, the.mortality has been great; relapses frequent; and the supervention of dysentery manifestly more frequent." 1 presume that the cinchona may be injurious, or beneficial, according to the period of the disease, or the circumstances under which it is administered. Where there are no violent visce- ral congestions—where the liver has resumed its regular action, and where, with these favourable circumstances the remission is complete, the bark or the quinine in large doses will often do a great deal of good. The authority of many of the most respectable of our south- ern brethren might be cited in confirmation of this remark. There can be no question, however, that so long as the liver remains torpid and engorged, or where strong local congestion, inflammation, or irritation is present, the bark will not only be useless, but, generally, decidedly injurious. No matter how slow and soft the pulse may be, so long as the abdomen remains tender to pressure, the tongue and skin dry, and the alvine discharges free from bile, bark and all other tonics are contra-indicated, and cannot be resorted to without great risk of irreparable injury. When, on the other hand, the occurrence of a remission is attended with a soft and moist skin and tongue, signs of bile in the stools, and freedom from abdominal tenderness, the quinine will, in general, prove highly beneficial. The affusion of cold water has been highly extolled by some, in the treatment of this disease. It does not appear, however, that this measure is calculated to do any good in the more violent grades of bilious remittents, where strong congestions and derangements of the biliary organs are present, or where the bowels are loaded with bi- lious and other saburral matter. (Richter.) Where these objections to its use do not exist, and the skin is very hot and dry, and violent pain in the head, with delirium, is present, cold water thrown on the patient will often produce prompt and manifest abatement of the febrile symptoms. It is, notwithstanding, a good general rule to delay the cold affusions until evacuations both by venesection and by the bowels have been premised; and above all, they must never be used unless the skin be dry and above the natural temperature. During the period of convalescence, mild tonics—such as infu- sions of cinchona, gentian, columbo, or serpentaria, will generally assist in restoring the tone of the digestive organs. The bowels must not be suffered to remain constipated; and the diet should be Vol. 1.—19 146 YELLOW FEVER. simple, mild, and digestible—such as animal broths, rice, barley, a little boiled or broiled mutton, lamb, or tender beef. CHAPTER VII. YELLOW FEVER. Synonymes.— Typhus Icterodes; Maladie de Siam; Bulam Fever; Vomitus Prieto; Causus. Yellow fever has been the theme of interminable discussion and controversy—a theme which has drawn forth the best and the worst feeling of the human heart—which has furnished motives, on the one hand, for the most active exertions of philanthropy and self- devotedness, and on the other, for all the bitterness and uncharita- bleness of feeling, which man, in his most degraded moments, is ca- pable of manifesting. There is no form of fever more variable in the violence and char- acter of its symptoms than the present one. In the seasoned and acclimated inhabitants of those regions where the disease is endemic, it is often as mild as ordinary bilious fever. But in the young and robust, who have not yet been seasoned to the climate, it seldom fails to make its attack with an overwhelming force; commencing and terminating in death, often within forty-eight hours, and sometimes sooner. The disease usually begins with a sudden feeling of giddiness, pain in the back, loins, and extremities, faintness and debility, with slight creeping chills, and nausea. After a period varying from a few to twelve hours, these symptoms are succeeded by a sudden develop- ment of vehement arterial reaction, accompanied with a dry and in- tensely hot skin, flushed face, red eyes, extreme headach, tormenting thirst, intolerance of light, pain in. the loins and lower extremities, a sensation of weight and tension at the stomach, white, and some- times clean tongue. Towards the end of the first twenty hours of fever, the patient begias to vomit frequently, particularly after tak- ing drinks. The ejections consist, at first, of such fluids, only, as may have been taken into the stomach; but after these have been thrown off, bile, often in abundance, is brought up, varying in co- lour from pale yellow to dark green, and frequently so acid as to excoriate the fauces and lips. The heat and tenderness in the epi- gastrium now increase, the countenance assumes an indescribable expression of distress and hopelessness; there is great restlessness and sighing, and more or less delirium, usually, supervenes. In some cases slight pain is experienced on swallowing; "and about yellow fever. 147 this time an urgent sensation of hunger often comes on, and a re- markable want of power in the lower extremities, resembling partial paralysis." This paroxysm lasts, commonly from twenty-four to thirty-six hours, but in some instances, considerably longer; and then all the symptoms, with the exception of the nausea and the vomiting, greatly abate—the pulse returning to its natural standard, and the skin acquiring a moist and temperate condition. So complete, indeed, is the remission in some cases, that the patient is induced to flatter himself that all danger is now passed. More commonly, however, the patient remains in a state of tranquil indifference, amounting to a sort of stupor, without any apparent concern as to present or future situation. This is an ominous calm; for after a few hours, the pain and burning sensation in the stomach return with increased violence; the vomiting becomes frequent and distressing—the fluid brought up containing minute flakes or flocculi, resembling the crust washed from a port-wine bottle, but little or no bilious matter. The desire for cool drinks is extremely urgent, but every thing which is swallowed is immediately rejected by the stomach, with great force. The eyes and skin about the neck and breast, now acquire a yellow hue. This second paroxysm continues, commonly, from twelve to thirty-six hours, and is succeeded by a new train of symptoms, which mark the last or third stage of the complaint. The pulse now sinks in frequency, force, and volume; the tongue is dark-brown or black; the vomiting becomes almost incessant, and exceedingly for- cible—the matter thrown up consisting of a black ropy fluid, resem- bling coffee-grounds suspended in a glairy liquid. The extremities become clammy and cold; and the acrid or burning sensation in the stomach, acquires a most distressing degree of violence. Diarrhoea usually occurs at this period—the discharges being green or black; "and the patient often complains of being unable to pass his stools, from a want of power in the abdominal muscles." By this time the whole surface of the body is a dirty yellow colour; and hiccough, haemorrhages, violent delirium, coma, insensibility, or convulsions, sooner or later terminate the patient's sufferings in death. Such is the ordinary course of this fatal malady. In many in- stances, however, the attack is much more overwhelming; the pa- tient being seized at once with loss of muscular power, and general oppression of the nervous system,—falling down as if stunned with a blow. In other instances, violent and furious delirium, or mania ushers in the disease, terminating in a few hours in insensibility and convulsions. Sometimes the disease commences and proceeds to a fatal termination in so insidious a manner, that the patient himself and those about him are scarcely aware that he is much indisposed. In such cases there is, however, always a remarkable change in the expression of the patient's countenance, as well as his usual temper and habits. In almost all instances of this disease, the countenance is expressive of intense anxiety and despair during its early period, and of gloomy or sullen abandonment in the last stage. 148 VELLOW FEVER. The period at which the skin begins to assume a yellow colour, is very variable. It sometimes occurs within the first forty-eight hours, and sometimes not until the fourth or fifth day. Various opinions have been expressed with regard to the immediate cause of this yellow hue of the surface. Some ascribe it to the serum ren- dered yellow by dissolved red globules of the blood, and effused under the cuticle. Dr. Fordyce attributes it to the superabundant secretion of sebaceous matter by the glands of the skin; and Dr. Saunders supposed it to depend on a peculiar state of the lymph in the subcutaneous cellular tissue. Many however maintain, and with correctness, I think, that the yellow hue, in question, is of anicteric character, depending entirely on the deposition of bilious matter un- der the cuticle. The black matter thrown from the stomach in the latter period of this disease, does not consist of bile, as was once generally supposed, but of minute flakes of coagulated blood suspended in the gastric mucus, produced by sanguineous exhalation from the abraded surface of the mucous membrane of the stomach. The black matter discharged in some of the higher grades of bilious and typhus fevers differs essentially from the "black vomit" of yellow fever. The former will dissolve in water, and communi- cate a deep bilious tinge to it; whereas the black matter which forms the black vomit of the present disease, consists of small inso- luble flakes, which are held suspended in a viscid fluid, and will not communicate a yellow or greenish tinge to water when agitated with it. "In taste also they differ. The black matter which occurs in common bilious fever is always intensely bitter; but that which is thrown up in yellow fever, is either insipid or acid."* (Bancroft.) Post mortem appearances.—The stomach and liver are the or- gans upon which the disease exerts its principal force. The former, especially, always shows the strongest marks of previous inflamma- tion and its consequences. Its coats are often thickened, and the mucous membrane is always strongly injected, abraded, and in many parts gangrenous, or totally disorganized. The duodenum and small intestines also almost invariably exhibit marks of inflammation. In many of the more aggravated cases, the liver undergoes much struc- tural derangement. Dr. Chisholm has found the liver "in a dis- solved or putrid state or sphacelated, and of the consistence, feel, * Mr. Lyon, staff surgeon in the Island of Dominica, says that the black mat- ter ejected from the stomach in yellow fever, is invariably very strongly acid. He ascribed the black colour of the blood to the action of muriatic acid on it; for it is this acid, which, according to the investigations of Prout and others, is secreted by the stomach in a state of disease. " Having made the experi- ment of adding muratic acid to blood, the colour of the blood was instantly changed to a deep black, and when diluted with water, presented a liquid, which I should have declared, from mere inspection, to be black vomit."—Lond. Med. and Phys. Journ. 1829. YELLOW FEVER. 149 and colour of rotten cork, or full of abscesses." Dr. Physick rarely found the liver much diseased, but the stomach was always inflamed and gangrenous in parts.* Cause.—In relation to the origin and mode of dissemination of yellow fever, physicians have been at great variance; and the sub- ject is still much disputed, although the weight of good testimony is greatly on the side of its miasmatic or domestic origin. After an attentive examination of the principal observations which have been published on this subject, it appears, indeed, difficult to adopt any other opinion, than that which alleges its origin from miasmatic efflu- via, "exhaled from masses of public filth containing putrescent mat- ter, generated under a high range of temperature." That this is the case, seems to be sufficiently demonstrated by the following cir- cumstances:—1. Yellow fever always appears in the lowest and most filthy parts of towns; and those localities in which it is most preva- lent, are in the immediate vicinity of marshes or soils favourable to the production of miasmata. 2. Yellow fever never occurs in cold seasons—a high range of atmospheric temperature being essential to the generation of its cause. 3. Heavy rains, storms, and the super- vention of cold weather, never fail to put an immediate check to the disease.t 4. Yellow fever always appears simultaneously, and is intermixed with bilious remittents. Dr. Ramsey states, that in the yellow fever of Charleston, in 1804, "neglected intermittent fre- quently terminated in yellow fever." Dr. Rush also states, in rela- tion to the yellow fever in this city in 1802, that "intermittents, the mild remittent, the inflammatory, bilious, and the malignant yellow fever, have, in many instances, all run into each other;"J and, he ob- serves, that Dr. Saunders, nearly a century ago, noticed this conver- sion of marsh and yellow fever into each other. Yellow fever is, moreover, always most severe in the immediate vicinity of those localities which favour the generation of marsh miasmata. Dr. Caldwell speaking of the yellow fever of this city in 1803, says, "as the fever receded from the low ground and malignant atmosphere of Water street, it became more and more mild and manageable till its evanescent shades in Second street, were, in .many instances, Auch lighter than the common remittent of the country." During the prevalence of the yellow fever in Baltimore, "the bilious or re- mitting fever in its ordinary form, prevailed in that town, and con- tinued until it was gradually lost in the severer form of yellow fever as the season advanced." (Davidge.) 5. The miasmatic origin of the disease may be inferred also from the fact, that the recurrence of it has often been, in a great measure, prevented by removing the sources of pestiferous exhalations, in situations where it formerly pre- vailed, almost annually, to an alarming extent. Our own city may be * New-York Medical Repository. | Rush's Medical Inquiries. X Medical Repository for 1802. 150 YELLOW FEVER. cited as a prominent example of the efficacy of cleanliness in pre- venting the occurrence of this disease. (Bancroft.) If these views be correct, in relation to the origin of the disease, we are forced to reject the opinion so stoutly maintained by some, of its being in any respect contagious. Indeed, if yellow fever did possess the power of gene- rating its own virus, and communicating itself by contagion, the fact, as Dr. Bancroft observes, must have been proved ten thousand times by the most irrefragable testimony, and yet there is, perhaps, no incontestible case on record where the disease was thus commu- nicated. The city hospitals established in the neighborhood of this city and at New-York, furnish us with a striking refutation of the supposed contagious nature of this disease; for, in no instance, was the disease communicated to those who were employed about the sick. The same observations were made at the encampment near Baltimore, during the prevalence of this disease in that city in 1819. The recent very ample investigation of this subject by Dr. Chervin, has resulted in a mass of testimony, which can scarcely leave any pretext for doubting the non-contagious nature of this disease. But, although yellow fever be not contagious, it may, no doubt, be in- troduced into seaport in ships. Unquestionably, a pestiferous miasm may, under favourable circumstances, be generated in the holds of ships while navigating in hot climates; which, when suffered to es- cape at the wharves, may give rise to the disease in question. When the miasmata are thus introduced, however, the disease engendered by it will not prevail epidemically, but only among those who ap- proach the infected vessel, or the cargoes, and will disappear entirely when these are removed to a distance. (Bancroft.) The sporadic cases which occured at the Wall, about 1804, at Perth-Amboy, in 1811, at Middletown, in Connecticut, in 1819, and at New-York, in 1824, were distinctly traced to vessels that had recently arrived from warm climates. The circumstances of the ship Ten Brothers, at Boston, in 1819, afford a striking example of the production of deleterious miasm in the holds of ships, capable of producing yellow fever.* This vessel having arrived at Boston on the first of August, a number of persons went on board while the cargo was being dis- charged; and out of these, twelve individuals, living in various parts of the city, were seized with malignant fever, nearly all of whom died. The disease was not, however, communicated to a single person of those who visited the sick. Observations would seem to show, that those who have once suf- fered an attack of this disease, are afterwards, in a great degree, insusceptible of another attack. In hot climates, where the disease is endemic, persons recently arrived from more temperate latitudes, are almost exclusively obnoxious to this disease. The acclimated are, in a great degree, exempt from its attacks, and when it does occur in such individuals, it almost always is of a comparatively mild and * Medical Recorder. YELLOW FEVER. 151 tractable character. The influence of the remote cause of this form of fever is greatly promoted by intemperance, excessive exercise in the sun, exposure to a damp and cold night air, and, in short, by whatever is capable of debilitating either the whole system, or de- ranging important organic functions. Treatment.—If yellow fever has been a fertile subject of dispute in relation to its pathology and cause, it has afforded no less scope for contention with regard to its remediate management. Whilst some strenuously recommend a prompt and energetic treatment; others condemning the lancet, mercury, and active purgation, advise nothing but the mildest and most soothing remedies. From a care- ful estimate of the best authorities on this head, however, it would appear that the chances of success are on the side of an energetic plan of treatment. This disease is highly phlogistic; and gastro- enteric inflammation is a very common occurrence—more especially in young, robust, and unacclimated subjects. In cases where the arterial reaction is vehement in the onset of the disease, general blood-letting is often promptly and conspicuously beneficial. To obtain the full advantages which this evacution is capable of afford- ing, it must be early and very efficiently practised. Those who have employed blood-letting with the greatest success, are unanimous in restricting its use to the first stage of the disease. Dr. Robertson, in his account of the yellow fever of New Orleans, states, that during the first twelve hours, he frequently drew from fifty to sixty ounces of blood ;* and Dr. Belcher bled to the extent of from fifty to eighty ounces in the first stage, with much advantage.t In a disease so impetuous in its attack, and so apt to develop local inflammations, much, and often every thing depends on an early and powerful antiphlogistic impression on the system. Where the reaction of the heart and arteries is vigorous, the blood should be suffered to flow until fainting approaches, "for it is not only by unloading the vessels, but by the shock also which it gives to the system, that blood-letting proves so serviceable in inflammatory fevers." Dr. Anthony Mus- grave states, that as soon as the febrile reaction was devoloped, after the invasion of the disease, he derived the greatest benefit from the immediate and rapid abstraction of blood, to an extent limited less by the quantity than by its decided effect upon the action of the heart and arteries.J Dr. Rush, as is well known to the profession of this country, was a zealous advocate for blood-letting in the dis- ease. " I paid no regard," he says, " to the dissolved state of the blood, when it appeared on the first, or second day of the disorder, but repeated the bleedings afterwards in every case when the pulse continued to indicate it." "In a disease like this," says Dr. Robert- son, "where the danger is frequently imminent in twelve hours, it * Johnson on Tropical Climates, vol. ii. f Edinburgh Med. and Surg. Journal, 1825. X Treatise on the Yellow Fever of Antigua. 152 YELLOW FEVER. is often surprising to see how much its apparent character may be altered by active depletion." A host of other able practitioners might be cited in behalf of the usefulness of this practice. In those instances of the disease, however, where the nervous system appears to be in a manner overwhelmed by the remote cause of the fever; when the patient exhibits an air of confusion or intoxication, with great agitation, "and a dash of wildness gleaming at intervals over his agonized features;" when he complains of little or no headach, but is impatient and irritable, yet oppressed; and after the first days, sinks down with a careless expression of resignation—in such cases blood-letting is wholly inadmissible. Here we must rely chiefly on the prompt and liberal administration of calomel with a view to its salivant operation. The efficient abstraction of blood in the commemcement of the disease serves not only to break down the violence of the phlogistic excitement, but often contributes materially towards allaying the excessive irritability of the stomach, frequently so distressing in this malady. Purgatives also are highly useful remedies in this disease, though, like blood-letting, their good effects are almost entirely confined to the early periods of the disease. Calomel and jalap, in doses of ten grains of each, was a favourite purgative with Dr. Rush. As calomel is, however, very generally admitted to be one of our most useful remedies in this disease, both on account of its purgative effects and its specific constitutional influence, it will be better to exhibit it by itself in doses of from ten to fifteen grains every three or four hours, and to promote its purgative operations by laxative enemata, after the second or third dose has been taken. In this way copious alvine discharges will generally be effected, and the system early brought under the mercurial influence. Should the bowels, however, hot be sufficiently evacuated by these measures, a dose of Epsom or Glauber salts ought to be administered. When the bowels have been thus once freely evacuated, they must be kept in a loose state by means of the milder laxatives; such as Seidlitz powders; small por- tions of the saline purgatives, or the occasional use of enemata. It should be observed, however, that mercury, with a view to its con- stitutional operation, can seldom be serviceable, so long as the arterial action remains unsubdued in the commencement of the disease. Indeed, almost all attempts to produce ptyalism under such circum- stances are fruitless. Decisive blood-letting in cases of this kind must be regarded as an essential preliminary to the use of mercurials. In cases of a less vehement grade of febrile reaction, where the disease assumes more of a congestive character, the early induction of saliva- tion is particularly desirable—and our principal object should be to produce this effect as speedily as possible. Dr. Musgrave observes, " that in the more concentrated form of yellow fever, experience leads me to believe that mercury, administered with a view to its salivant effects, may be judiciously dispensed with. But there is a form of YELLOW FEVER. 153 this disease which, from its insidious approach, is peculiarly calculated to lull the patient into mistaken security," and thus to baffle, in its subsequent progress, the best directed efforts; and this form is un- doubtedly treated with great success by the rapid induction of ptyalism.* In cases where the febrile reaction is strongly developed, the skin is always extremely hot and dry during the first period of the disease, and nothing is more refreshing than sponging or ablutions with cold water under such circumstances. Most writers prefer pouring it forcibly on the patient's body. Dr. Johnson observes, that "the greater the force with which the water is applied, the more benefit will be derived from it."t When the head is mfich affected during the first stage, considerable benefit may be obtained from cold appli- cations to the shaven scalp. Bladders partly filled with water, con- taining a lump of ice, is the most convenient and effectual mode of applying cold to the head. For the same purpose blisters are recommended by some, but their usefulness in this respect is very questionable, and certainly much inferior to the application of cold, so long as the arterial reaction is vehement. Draughts of cold water are generally very grateful to the patient, and have the effect often of moderating the heat, predisposing to perspiration, and of relieving the gastric distress. (Johnson.) Emetics are very generally, and with justice, condemned in the treatment of this disease. The gastric irritability and tendency to inflammation is so great in this affection, that mischief would almost inevitably result from the operations of this class of remedies. Nevertheless, we are told by Dr. M'Arthur, that where the disease commences with diarrhoea, or dysenteric symp- toms, emetics may be frequently given with considerable advantage. Besides the means already mentioned for allaying the extreme ir- ritability of the stomach, and restraining the vomiting so distress- ing in the disease, we may also derive much advantage from the application of leeches or blisters to the epigastrium, more especially after the impetus of the circulation has been in some degree mode- rated by an efficient bleeding. When the disease has passed on to the second period, we must depend on the use of mild aperients, diaphoretic and cooling beverages, enemata, cold affusions when the skin is hot and dry, and calomel, in reduced doses. A great deal, however, of the success of our remediate efforts depends on the pro- per management of the disease in the first period. As a diaphoretic, we may use the spiritus mindereri, or the saline effervescing draught. When, after the second exacerbation, the pulse and temperature sink, recourse should be had to the active tonics—arxl of these, the cin- chona or quinine is the most efficient. The latter, especially, seems to have done much good in this disease.:}: These articles should be * Edinburg Med. and Surg. Journal, 1827. f Influence of Tropical Climates, vol. ii. p. 182. X Journal des auslandishen Literature, &c. Von Drs. Julius and Gerson. Vol. I.—20 154 CONTINUED FEVER. administered in as large and frequent doses as the stomach will bear. Dr. Musgrave resorted to the cinchona in the less vehement cases, with much good effect, as early as the first remission, having pre- viously evacuated the bowels thoroughly. From five to ten grains of quinine may be given every hour or two during the remissions, and it may be given in conjunction with calomel, during the first periods of the disease. In the latter stage of the disease, the bark, quinine, wine, and ammonia, constitute almost the only remedies that can be employed with any prospect of advantage. Stimulants, however, are not so well calculated to do good in the sinking stage of this form of fever, as in that of typhui The spirits of turpentine has also been recom- mended in the treatment of yellow fever, but it does not appear that its powers are sufficiently valuable in this respect to entitle it to much attention. It is proper to state that many of the West India practitioners adopt a plan of treatment far less energetic than the one just detailed. They employ little else than mild aperients, with copious draughts of acidulated drinks, enemata, and external cold applications. CHAPTER VIII. CONTINUED FEVER. Although the varieties of fever which are arranged under the present general head are termed continued, in contradistinction to the forms of fever considered in the two preceding chapters, yet, with the exception of the ephemera, a fever strictly continuous or unremitting in its course, is in reality a phenomenon of the rarest occurrence. Whether the operations of the animal economy be car- ried on in a state of health or of disease, regular periodical fluctua- tions appear constantly to obtain in the excitement or actions of the system. In every form and variety of fever, there seems to exist a natural tendency in the general morbid excitement or symptoms, to remit or abate in their violence at some period during the day; and this remission, in perhaps ninety-nine cases out of a hundred, occurs during the morning. In the fevers denominated continued, how- ever, these temporary abatements in the violence of the symptoms are generally slight, and frequently very transient; they usually occur very early in the morning, and seem to be the result of the abstraction of the stimulus of light, sound, &c. during the night, in conjunction with the natural tendency of the actions of the system to abate at this period. Continued fever occurs under a variety of prominent modifica- CONTINUED FEVER. 155 lions; and under every grade of febrile excitement, from the feeble and sinking reaction of typhus, to the vehement and tumultuous ac- tions of synochal fever. Agreeably to this circumstance, it has been customary to divide continued fevers into sthenic and asthenic, or inflammatory and typhus. That there exists a very material dif- ference between the low fevers denominated typhus, and those usu- ally termed inflammatory, is quite obvious. The term inflammatory, nevertheless, does not seem to be strictly appropriate as a distinctive appellative in this place; for that irritated excitement which consti- tutes fever is always necessarily inflammatory in its general charac- ter, whether the reaction be feeble and sinking, or vigorous and ardent. Mere grade of energy or activity, is to be regarded as an accidental and variable quality of inflammatory excitement. Fever consists essentially in an irritated action of the sanguiferous system, and this irritated condition may be connected either with increased or decreased energy-of the vital powers. In pure synocha, the heart and arteries are in a state of morbid action, with increased powers of acting; whilst in typhous fevers the general irritated excitement is connected with fundamental debility of the vital powers. In either case, however, the irritated vascular action is essentially phlogistic, and equally prone to give rise to local inflammations. The diversi- ties which occur in the general character of continued fevers, depend mainly on the differences which occur in relation to the degree of vital energy enjoyed by the system, and this diversity in the general energies of the system itself, would seem to depend on the greater or less degree in which the nervous system becomes implicated in the disease. The brain is the fountain whence the animal economy draws its powers of action; and whenever this source of the vital forces becomes injured or impeded in its operations, debility, cor- responding to the degree and character of the cerebral affection, will be manifested in the actions of the system. In the high and vigo- rous synochal fevers, there are rarely any considerable manifestations of cerebral disturbance; whereas, in all those fevers which are attend- ed with prostration or feebleness, the brain and nerves are generally prominently disordered throughout the whole course. There exists no small degree of difficulty in arranging continued fevers under such heads as will exhibit a distinct and comprehensive view of all the prominent modifications or forms in which they are wont to occur. In relation to the grade of febrile excitement, fevers may be divided into three principal varieties: namely, synocha, synochus, and typhus. 1. Synocha.—This head embraces all those fevers which are conspicuously inflammatory, both in relation to their general and local phenomena. They are usually divided into idiopathic and symptomatic; the former, constituting what is generally termed simple inflammatory fever; and the latter, embracing those ftsvers which result from acute local inflammation. Hardness, quickness, and tension of the pulse, are essential characteristics of synochal 156 CONTINUED FEVER. fever; but in relation to the size and activity of the pulse, there exists great diversity in the different varieties of this grade of fever. In simple inflammatory fever the pulse is full, vigorous, and hard; whilst in some of the phlegmasia, in acute gastritis, enteritis, and peritonitis, its volume is usually small, although its firmness, tension, and quickness are conspicuous, and the necessity of prompt and vi- gorous depletory measures extremely urgent. The blood in synocha is thicker, and contains a smaller proportion of serum than in health, and is disposed to separate speedily and very completely into its constituent parts. The crassamentum becomes dense, concave, or cupped on its superior surface, and coated with a thick layer of yel- lowish fibrine. The albumenoid, or coagulable portion of the serum, does not become condensed when subjected to the action of heat, alcohol, &c. but is converted into a white pap-like matter. Boiling water poured into the serum of blood taken from a patient labouring under synocha, converts it into a whey-like fluid, resembling a solu- tion of soap in water, without any coagulated flakes.* In synocha, the general energies of the system manifest no prone- ness to prostration, so long as the fever retains its simple character. The powers of vital resistance continue to the end, with no material impairment. When general fever of the synochal grade passes into a low or typhoid state, it is either in consequence of inordinate sangui- neous depletion, or of the supervention of cerebral inflammation, or the occurrence of inflammation and gangrene in other organs. Simple continued fever of the synochal grade, is rarely attended with conspicuous symptoms of sensorial disturbance, or cerebral irritation; nor is it common to meet with signs of gastro-intestinal irritation in cases of this kind. Fevers, however, rarely preserve the simple synochal character throughout their whole course. In most instances, local inflammation supervenes in some part or other. When the inflammation falls upon a fibrous structure, or upon one of the solid viscera, the energy of the febrile reaction will be in- creased, or at least sustained; but when it happens to appear in the mucous membrane of the alimentary canal, the brain generally be- comes more or less oppressed, and the general powers of the system tend to a state of prostration. The secretions in synocha are almost universally diminished in quantity. Cold or atmospheric vicissitudes, and a high degree of solar heat, are almost the only general causes of this grade of fever. Synochus.—This grade of fever is intermediate between the purely synochal and the typhus varieties of fever, and constitutes by far the most common modification of febrile reaction. It is the grade of fever which occurs in intermittents, remittents, bilious fever, and the common continued fevers which arise from cold and from * Reil. uber die Erkentniss, &c. der Fieber. Band. i. s. 494. See also Par- mentier and Deyeux's Memoir in Reil's Archives fur die Physiologe and B. 1. No. 3. s.5. CONTINUED FEVER. 157 gastric irritation. The pulse of synochus fever is active, more or less full, frequent, compressible, and free from unusual tension or hardness. The blood itself rarely differs perceptibly from its nat- ural character, being devoid of the above named inflammatory charac- teristics. The system is much less able to resist the influence of debilitating causes than under the preceding grade of fever. It will bear a degree of depletion while labouring under synocha, which, in a fever of the synochus grade would produce the utmost degree of prostration. Synochus is employed here as indicating merely a certain grade of febrile excitement, and not as constituting in itself a distinct form of fever. The reaction of the heart and arteries is only one of the series of morbid phenomena which constitute fever, and the same grade of vascular reaction occurs in maladies essentially distinct from each other. So far, indeed, as the mere action of the heart and arteries is concerned, fevers differ from each other only in de- gree; or, to adopt the language of Parry, in the greater or less mo- mentum of the blood. It is in the capillary system of vessels, that the fundamental morbid condition resides, which establishes the essential difference of febrile diseases. The morbid excitement of the capillaries in a case of small-pox must be very different, one should think, from that which occurs in this system of vessels in remitting fever, and both may nevertheless be attended with the synochus grade of febrile reaction. Typhous.—This grade of fever is lower than the preceding one, the vital powers being more prone to sink, and in general much less able to resist the influence of debilitating remediate measures. It is characterized by a weak, small, quick, and generally frequent pulse. In some instances, however, of a typhous state of fever, the pulse is nearly natural in frequency and fulness; but softness and feebleness are seldom absent, except in the commencement of the disease. An early disturbance of the sensorial powers, and a train of various nervous symptoms, almost universally attend fevers of the typhus kind. There are three apparently very distinct varieties of typhus fever. One of these varieties is characterized by what may be called a highly nervous state of the system—the patient manifesting along with a weak condition of the vital powers, a peculiar degree of ner- vous excitability and excitation, and an active state of the sensorial functions. This constitutes what was formerly usually described under the name of nervous fever, the typhus nervosus, pyrexia nervosa, neuropyra} typhus cum erethismo, and the febris nervosa simplex of authors. Another variety of typhous fever in connexion with the deficient or sinking energies of the system, is characterized in its progress by phenomena which have been generally regarded as indicative of a ten- dency to putridity; the pulse, at first moderately full and active, soon becomes soft, feeble, some times frequent, and at others slower than 158 SYNOCHA, OR natural, the skin is pale-dingy, or sallow, its heat elevated, and of the kind called calor mordax, or in some instances nearly natural, and sometimes even below the natural'standard. The breath, secre- tions, and exhalations, are offensive to the smell, petechias, extravasa- tions, colliquative haemorrhages from the gums, the fauces, the eyes, the bowels, &c. ensue towards the conclusion of fatal cases. This variety of typhus fever has been described under various denomina- tions; such as/ colliquativa, f. putrida sanguinea, f. putrida simplex, f. sepedogenetica,f. adynamica, typhus putridus, syno- chus putridus, pyrexia myoica, pyrexia denophlebica, f. hsema- toseptica, septopyra, putrid fever, putrid nervous fever, typhus gravior, &c. There is a third variety of low fever, which, along with its radical tendency to prostration, is strongly characterized by a very con- spicuous torpor of the sensorial, intellectual, and general nervous functions. Its first stage is often attended by the synochus grade of vascular reaction, whilst the second stage is marked by torpor, great prostration, and feeble arterial action. Its different stages are more definite in their duration, and its essential phenomena succeed each other in a more regular order than those of other continued fevers. This constitutes the genuine typhus—the typhus conta- giosus of authors—a form of fever which by many is believed, and I think with correctness, to be radically diverse from every other form and variety of febrile disease. Having made these general remarks on the principal grades and modifications of continued fevers, I pass on to the consideration of particular forms of fever. Sect. I.—The Synochal grade of Idiopathic Fever, or Simple Inflammatory Fever; Febris Irritativa; Pyrexia Sthenica; Febris Vasorum; Inflammatoria; Enechia Cauma. This variety of continued fever is attended with the highest grade of febrile excitement, associated with increased irritability, as well as increased power of action in the heart and arteries. The pre- monitory stage is always short, the fever coming on suddenly with distinct chills or rigours, the febrile reaction is rapidly developed, the whole surface becoming speedily intensely hot,* the pulse full * The heat of the skin is of the kind usually called burning, in contradistinction to that peculiar biting or acrid heat which occurs in typhus fevers, termed calor mordax. By laying the hand on the skin of a patient labouring under inflam- matory fever, the sensation of heat communicated is at first very considerable, but on suffering the hand to remain for a short time, the sensation of heat grad- ually diminishes, until it seems to the touch but little above the natural tempe- rature of the body. In typhus, on the contrary, the longer the hand is suffered to be in contact with the patient's body, the more pungent and perceptible does SIMPLE INFLAMMATORY FEVER. 159 and vigorous, and rarely above one hundred and twelve in a minute, the face flushed and turgid, the eyes suffused, sparkling, and unusu- ally sensible to the light, the temples and carotids throbbing, the head painful, the mouth and throat very dry, the breathing oppressed and hurried, the thirst for cold water very urgent, the tongue co- vered with a white fur, the bowels torpid, the urine very high- coloured, and small in quantity, the skin dry, harsh, and suffused with a slight blush, and the ears morbidly sensible to sounds. Deli- rium is not a usual occurrence in this variety of fever; but when it does supervene it generally becomes extremely violent, and greatly increases the unfavourableness of the case from its dependence, generally, on cerebral inflammation. The blood, when drawn, ex- hibits the inflammatory character already mentioned, i. e. the buffy coat,* cupped crassamentum, and paucity of serum, &c. These symptoms usually suffer regular remissions and exacerba- tions; the former occurring in the morning, and the latter in the evening, until they finally terminate entirely under some critical evacuation. Simple synocha, or inflammatory fever, very rarely continues beyond the ninth day, and still more rarely beyond the fourteenth, and not unfrequently terminates its course as early as the fifth or seventh day. When the termination occurs about the seventh day, the symptoms usually go on increasing in violence to the fourth or fifth day; and when the disease is prolonged to the fourteenth day, the increase generally continues to the ninth, or per- haps the eleventh day. The resolution of inflammatory fever is almost invariably accom- panied by general and free perspiration, together with its never-fail- ing concomitant, a reddish or pale sediment in the urine. In some instances, a slight haemorrhage, particularly from the nose, accompa- nies the crisis. In general, these critical discharges take place a few hours after an evening exacerbation, and this exacerbation is often ushered in by a slight chill. Inflammatory fever does not, however, often continue its course throughout in the regular and simple form which has just been de- scribed. Topical inflammations, of more or less intensity, very sel- dom remain wholly absent in the progress of the disease. The human system is rarely in such a condition as that some organ or structure is not in a state of predisposition to inflammation; and there can scarcely be a circumstance better calculated to produce the heat (calor mordax) become, and the biting or acrid sensation of heat re- mains in the hand even after it is removed from the patient. * The buffy coat, which occurs in inflammatory fevers, differs from a some- what similar appearance observed sometimes on the blood of typhus patients. The former is of a uniform yellowish colour, and very tenacious, whereas the latter is brittle, of a paler yellow, and presents an iridescent appearance, re- flecting some of the colours of the rainbow when held in certain positions to the light. 160 SYNOCHA, OR inflammation in a part thus predisposed, than the very greatly aug- mented momentum and peculiar condition of the blood, which exist in this variety of fever. When local inflammation supervenes in the course of a simple synochal fever, the general aspect and dispo- sition of the disease will, of course, be considerably altered. Some- times the brain and its meninges become inflamed, at an early period of the disease; but this occurrence is much less common in the sy- nochal, than in the synochus and typhus grades of idiopathic fever. Occasionally synochal fever, after having continued for a day or two, becomes complicated with rheumatic inflammation; and in some instances inflammation occurs in one or more of the thoracic or ab- dominal organs. In general the more the brain becomes affected, either by inflammation or sympathetic irritation, the more apt will the system be to sink into a state of prostration or oppression. When the febrile reaction is extremely vehement, or the system habitually delicate and feeble, simple inflammatory fever sometimes exhausts the vital energies, and passes into a low or typhoid state. The constitutional predisposition to synochal fever would seem to consist in a vigorous condition of the vital powers, robust health, activity of the digestive and nutritive functions, and an irritable plethoric habit. Persons between the fifteenth and fortieth year of age, of a sanguineo-athletic temperament, appear to be most liable to fever of this vehement character. In early infancy, and in old age, simple inflammatory fever is not so often found to occur as during the intermediate periods of life. Causes.—The exciting causes of inflammatory fever are very various. This grade of fever may be produced by cold, atmospheric vicissitudes, high solar heat, the intemperate use of spirituous liquors, too free an indulgence in high-seasoned and irritating articles of food, the sudden suppression of natural or habitual evacuations, exces- sive corporeal exertions, a draught of cold water when the body is heated by exercise, violent passion, mechanical injuries, &c. Of all these causes of synochal fever, however, cold is by far the most common. It is from the extensive influence of this febrific cause that continued fevers of a synochal grade are so common in cold and variable climates, and during the cold and changeable months of spring and autumn in the temperate latitudes. During the summer months we seldom meet with general fevers of a very phlogistic character; and pure synochal fevers are perhaps still less common in the intertropical climates. Prevailing north-west and north-east winds are particularly favourable to the occurrence of inflammatory fevers. So remarkably is this the case, that typhus fevers will sometimes assume, for a time, a decidedly phlogistic character, if the wind shift suddenly from a southern to a northern point. May not the electric changes of the atmosphere have some agency in the production of this effect? From the influence which atmospheric vicissitudes and sudden variations in the direction of prevailing winds are sometimes found to have on patients and con- SIMPLE INFLAMMATORY FEVER. 161 valescents confined in close chambers, or even in bed, this supposi- tion does not seem to be improbable. There are, indeed, some writers who contend that a superabundance of electricity in the at- mosphere constitutes the cause of epidemic inflammatory fevers. Hopf observes, that fevers of this kind are always most apt to pre- vail during those seasons and meteorological conditions, when the atmosphere is most charged with the electric fluid. Reil thinks that electricity often contributes considerably to the production of phlogistic fevers by increasing the general irritability of the system.* It may be observed, however, that the grade or modification of a fever, does not depend so much on the character of the remote or exciting cause, as upon the peculiar condition of the animal system at the time the cause exerts its morbific influence. Thus, the same degree of cold may produce a low or typhoid fever in one, and a vehement inflammatory fever in another individual—a circumstance which proves unequivocally that such diversities depend mainly, and often wholly, on the peculiar predisposing condition of the body itself. If of two individuals seized with fever from the same atmospheric vicissitude, one be especially prone to inflammation of the brain or of the mucous membrane of the alimentary canal, and the other to inflammation of the fibrous and serous structures, or be wholly free from any local predispositions of this kind, the fever will most pro- bably early assume a low or typhoid grade of vascular reaction in the first, whilst in the latter it will be apt to retain its vigorous synochal character throughout its course. When speaking of the general character and etiology of fever, I observed that in simple inflammatory or synochal ievev, the princi- pal febrific irritation is, probably, located in the vascular system— that is, in the internal membrane of the heart, arteries, and capilla- ries. In those general inflammatory fevers which arise from the influence of cold, at least, this is probably the case; for, in instances of this kind, besides the internal congestions and inequilibrium of excitement resulting directly from the impressions of this cause, a large proportion of the recrementitious elements of perspirable mat- ter must remain mingled with the blood, (unless speedily removed by the vicarious action of some other emunctory,) and necessarily impart to this fluid qualities which are not natural to it. Most as- suredly the retention of materials which have become useless to the system, and for whose constant elimination nature has provided so extensive a series of emunctories as the cutaneous exhalents, cannot be long tolerated by the animal economy with entire impunity. The blood is the natural stimulant of the sanguiferous vessels, and * Hopf, Dissertat. sistens rudimenla theor. de principio febres inflam. epide- mica gignente. Reil. liber die erkentniss und kur der Fieber. Band. i. s. 501. See also Gautier's work, entitled, Commentatio medica de irritabilitatis notione, natura et morb. p. 21. Vol. I.—21 162 SYNOCHA, &C we must believe that its stimulating qualities are naturally in due and harmonious relation with the sensibility and irritability of its appropriate vessels. When, therefore, in consequence of suppressed perspiration, this fluid becomes surcharged with the elements of recrementitious perspirable matter, its natural relations with the heart, arteries, and capillaries will be destroyed, and irritation more or less intense must almost necessarily ensue. Why such a cause should produce typhoid fever in one, synochus in another, and pure synocha in a third individual, we may not be able to ascertain; but the grade of fever is, no doubt, determined by the particular con- dition of the system in relation to accidental or habitual debility, local disorder or predisposition, temperament, modes of living—in short, every thing which constitutes a deviation from perfect health. That the degree in which the sensorium commune becomes impli- cated, has an important share in determining the grade of febrile reaction, has already been observed in several places. It would, indeed, seem very reasonable to conclude, that as the powers of the system depend mainly on the regular supply of the nervous influ- ence, the more the brain, its fountain, becomes involved in disease, the feebler will be the powers of the vascular and muscular systems. All low or typhoid fevers, in truth, are characterized by early and conspicuous manifestations of cerebral disturbance, and the prostra- tion, and encephalic disorder generally increase, pari passu. In fevers of the synochal grade, on the contrary, the brain and nerves suffersbut little; and, when inflammation of the brain does supervene, the system and vascular reaction soon sink to a lower grade. The prognosis in simple inflammatory fever is, in general, favour- able. This, indeed, may be regarded as the least dangerous of all the varieties of continued fever, so long as it retains its simple form. When local inflammation supervenes, the danger will be more or less increased, according to the importance of the organ or structure in which the inflammation occurs, or the variety and force of its sympathetic connexions, and according also to the intensity of the inflammation. When the breathing is free, and without cough or pain in the chest, and the abdomen neither tender nor tense to the touch, we may conclude that the fever is not of a dangerous charac- ter, from the almost certain absence of thoracic and abdominal inflammations. Slight delirium during the exacerbations is not to be considered as a very unfavourable symptom; when it becomes very violent, however, it betokens encephalic inflammation; and, of course, indicative of greatly increased danger. Richter says, that a very profuse discharge of limpid urine, occurring suddenly; liquid or watery discharges from the bowels; and very copious sweats without sedimentous urine and abatement of the symptoms, consti- tute very unfavourable signs in synochal fever. The signs which announce a favourable change are, the occur- rence of slight haemorrhage from the nose; general perspiration, at- tended with pale urine, becoming turbid when cool; and diminution COMMON CONTINUED SYNOCHUS FEVER. 163 in the frequency, hardness, and activity of the pulse, and in the febrile temperature of the surface. Sect. II.— The Synochus grade of Idiopathic Fever. Common Continued Synochus Fever (Synochus Simplex.) The ordinary continued fevers, those which are most frequently encountered in practice, though phlogistic in their character, do not manifest that intense grade of inflammatory excitement and perma- nency of vital resistance which characterize the variety of fever described in the preceding section. In the simple continued fevers which form the subject of the present section, there exists, as in pure synocha, strong febrile reaction; but the vital powers are not suffi- ciently sustained to enable them to maintain this elevated and ener- getic grade of morbid excitement—and hence, although the fever may commence with a degree of vascular reaction and general strength differing but very little from synocha, yet, both the grade of febrile excitement and the general powers of life will soon de- crease conspicuously, and verge to the low or typhoid state. The principal sources of this modification of continued fever are, cold or atmospheric vicissitudes, and irritation or disorder of the alimentary canal and of the biliary organs. Cold, however, is de- cidedly the most common source of the ordinary continued fevers of the temperate and more northern latitudes. When the disease arises from this cause, it is generally more phlogistic in its early periods, than when it occurs as the consequence of gastro-intestinal disorder or other febrific circumstances. The status gastricus of the German pathologists, is, nevertheless, almost invariably present in every modification of continued fever of the synochus grade. An early occurrence of nausea, vomiting, foul tongue, and disagree- able gastric sensations, are among the most frequent symptoms of common continued fevers. In this respect, common continued fever of the synochus grade, differs from synocha or pure inflammatory fever; the latter being but rarely attended by very manifest signs of gastric disturbance. Simple continued synochus fever occurs under various modifica- tions, many of which have been described by authors as distinct varieties of fever. The ordinary continued fevers of our cold and variable seasons, depending on the febrific influence of low tempe- rature or sudden atmospheric vicissitudes, occur under various grades of violence from the simple febrile state called a cold, to the most aggravated fever tending rapidly to cerebral oppression and fatal collapse. In the mildest modification, a slight and transient feeling of chil- liness is succeeded by a moderate increase of heat on the surface; a white tongue; some increase in the frequency, quickness, and ful- ness of the pulse; corporeal and mental languor; dryness of the skin; more or less pain over the eye-brows; a red and slightly di- 164 COMMON CONTINUED minished urine; slowness of the bowels, and disturbed sleep. In some instances, the appetite is but little impaired, but most commonly it is suppressed. This grade of fever generally passes off in a few days, under a gentle perspiration or moderate diarrhoea. The modification, however, which is especially designated by the name of common continued fever, is, by no means, so mild in its symptoms or so transient in its duration, and may be considered, in its more aggravated character, as one of the most formidable of general febrile maladies. This modification of the disease is gene- rally ushered in by a distinct cold stage, characterized by great las- situde, restlessness, a feeling of tension and confusion in the brain, oppressed and anxious breathing, feebleness, and quickness of pulse, a clammy tongue, disgust for food, flatulency, and frequently nausea, retching, or vomiting. This stage, alternating towards its conclusion with flushes of heat, often continues for many hours before the stage of excitement is fully developed. The skin now becomes hot, dry, and suffused with a uniform, but slight tint of red; the pulse more frequent, full, and active; the face flushed; a dull, heavy, or throb- bing pain is experienced in the head; the patient is restless, morose, or peevish, and feels unable to fix his attention, or to exert his men- tal faculties; his tongue is at first white, becoming dry, harsh, and dark-brown as the disease advances; the urine is generally red, sometimes pale, and wholly without sediment; the bowels are torpid, and the alvine discharges soft, and often of a clay-coloured appear- ance. There is, generally, from the beginning, some degree of in- tolerance of light and sound, and the carotids and temporal arteries usually beat strongly. These symptoms commonly go on for five or six days without any material changes, except the slight remis- sions and exacerbations which occur in the morning and during the night. Slight delirium commonly occurs during the night for the first five or six days; as the disease continues, however, the symp- toms of cerebral disorder become more and more conspicuous, so that, by the eighth or ninth day, it arrives at its acme, and either gradually declines under a favourable crisis, or passes, more or less rapidly, into a typhous condition or collapse, attended with almost constant delirium, partial stupor, dilated pupils, dry, foul, and dark- brown tongue, sordes about the teeth, hurried breathing, subsultus tendinum, picking at the bed-clothes; the pulse becoming progres- sively weaker, smaller, and more frequent, and the vital energies sinking more and more until death takes place about the 15th, or perhaps the 17th day, and sometimes not until a later period. In some instances of common continued fever, the symptoms of cerebral irritation are considerable at an early period of the disease, and the nervous or typhous stage supervenes rapidly and under a highly aggravated train of phenomena. With the development of the stage of excitement, which comes on slowly after a#protracted and oppressive cold stage, strong manifestations of cerebral disorder ensue. The patient evinces great aversion to light and sound; he * Clinique Medicale, t. iii. p. 13. PHTHISIS PULMONALIS. 357 tubes, is discharged by expectoration, leaving a kind of fistulous ca- vity. These tubercular excavations become lined with " a#species of morbid membrane, of a white and opaque appearance, and very soft consistence; external to which, another membrane of a semi-cartila- ginous structure is formed. Bayle thinks, that the pus expectorated in scrofulous consumption is secreted chiefly by the lining membrane of the tubercular cavities; but Laennec asserts, that the greater part of the purulent matter expectorated proceeds from the mucous mem- brane of the bronchia, which always suffers irritation and chronic inflammation, to a greater or less extent, in every variety of pulmo- nary consumption. Purulent expectoration from this source occurs in some instances of tubercular lungs, even before the tubercles have undergone the process of softening. Every case of tubercular phthisis, consists therefore of at least two, and sometimes three, simultaneous processes;-namely, 1, "the proper tubercular action either in a state of growth or increase, or in that of softening or de- struction; 2, of a degree of chronic inflammation of the mucous membrane of the bronchia; and, 3, sometimes of inflammation of the pulmonic tissue, of a chronic character, and tending to hepati- zation." Causes.—As has already been stated, persons may be decidedly predisposed to phthisis, and even affected with a tubercular state of the lungs, and yet escape the disease, if no adequate exciting cause supervene to rouse it into action. In some instances, functional or organic diseases of the liver develops the disease where the predis- position to it exists. Catarrhal affections, however, are by far the most common exciting causes of the disease. The tubercles may also be excited into action by a fixed irritation located in any of the principal viscera, more especially in the alimentary canal. Repelled cutaneous eruptions have a strong tendency to develop the tubercu- lar action, as indeed all other morbid impressions on the skin have in subjects of a phthisical habit. The sympathy between the exter- nal surface and the lungs is intimate and strong, and an irritation seated in the former, seldom fails to manifest itself in the latter organ—more especially when the lungs are in a state of habitual debility or predisposition to morbid action. It is on this account, that phthisis pulmonalis is so common a disease in cold and variable climates, where the cutaneous function is so liable to sudden' and frequent interruptions or variations of activity. Among the ordi- nary exciting causes of this affection, we may also mention the heal- ing up of old discharging sores; atmospheric vicissitudes; the abuse of mercury; intemperance in the use of spirituous liquors; sedentary occupations; excessive venereal indulgence, and onanism; copious losses of blood; the depressing passions; the admission of irritating vapours or fine particles into the lungs—to which latter cause, stone- cutters, glass-grinders, millers, needle-grinders, &c. are particularly exposed. * Prognosis.—The different varieties of pulmonary disease men- 358 PHTHISIS PULMONALIS. tioned above, vary very considerably in the degree of sanability, peculiar to them respectively. That form of consumptive disease, which depends upon chronic bronchial inflammation, is by far the most under the control of judicious remediate treatment; and where the mucous tissue remains free from ulceration, or the subjacent pul- monic structure has not become consolidated, recoveries are by no means uncommon. Laryngeal and tracheal consumptions are extremely dangerous affections. I have never known an instance of recovery from this variety of the disease. Cases of recovery have, however, been rela- ted by authors, but the number of such instances is very limited. Consumption from chronic pleuritis, is much more difficult of cure than that which depends on chronic inflammation of the mucous membrane of the lungs; yet in some instances, the disease subsides, and the patient regains a considerable degree of health. When a cure is effected, the effused fluid is either gradually absorbed while the lung expands, or it is discharged through the lungs by an opening into the bronchial tubes from the cavity of the pleura, or it escapes externally by an opening into the cavity of the chest through the intercostal spaces. Tubercular consumption may be regarded as an incurable dis- ease; for tubercular matter, so far as we know, is wholly incapable of being absorbed or otherwise removed. " Previously to the know- ledge of the true character and mode of development of tubercles," says Laennec, " and while consumption was considered as a conse- quence of chronic inflammation, and slow suppuration of the pulmo- nary tissue, medical men did not question the possibility of curing this disease by a suitable mode of treatment, especially if taken in time, and during the first stage. It is now, however, the general opinion of all those who are acquainted with the actual state of our knowledge respecting the pathology of diseases, that the tubercular affection, like cancer, is absolutely incurable, inasmuch as nature's efforts towards effecting a cure are injurious, and those of art use- less." However impossible it may be to remove tubercular matter when once formed, or to cure consumption depending on it, there can exist no doubt that we may occasionally so retard, or even arrest its progress by proper management, as to prolong life to a very con- siderable extent. Nay, it is equally certain, that by carefully avoid- ing those causes which tend to favour the conversion of tubercular matter into a pus-like fluid, persons who are manifestly strumous, or affected with incipient tubercles in the lungs, may pass through a long life without the actual development of consumptive symptoms. Although tubercular consumption may be regarded as incurable by art, yet in some rare cases a spontaneous cure has taken place after the softening of the tubercular matter and the formation of an ulcerous excavation. Laennec, upon whose authority this statement is made, mentions two cases which terminated favourably in this way. Such cures, he says, are affected in two ways; 1. by the cavity becoming PHTHISIS PULMONALIS. 359 invested by a new membrane of a semi-cartilaginous structure, which, when completely formed, constitutes a kind of internal cica- trix, analogous to a fistula, and " is, in many cases, not more inju- rious to health than this species of morbid affection;" 2. the cure may also be effected by a spontaneous obliteration of the cavity by a cacatrix consisting of cellular, fibrous, or cartilaginous structure. Such cures, are, however, extremely rare, and depend in no manner on medical treatment.—(Laennec.) Treatment.—Of the treatment appropriate to catarrhal consump- tion, I have already spoken fully, under the head of chronic bron- chitis, and the subsequent therapeutic observations refer chiefly to tubercular phthisis. Notwithstanding the uncontrollable and fatal character of tubercular consumption when once fully developed, patients labouring under this form of disease are not to be abandoned to their fate, without making an effort to arrest, or at least to retard its progress; for although the hope of curing the malady, after its complete establishment, is wholly fallacious, experience has fully demonstrated the fact, that, by judicious management, we may often keep the tubercles in a dormant state, interrupt their progress, or at least greatly retard their passage into an active condition. In consumptive habits, every thing which tends to irritate the system, more especially the respiratory organs, should be carefully avoided. Attention ought, above all, to be directed to the regular maintenance of the perspiratory function; and with this view, the patient should be directed to wear flannel next his skin; to protect himself by proper clothing against the influence of low temperature; and to avoid, as much as his circumstances may admit, the effects of atmos- pheric vicissitudes. In the incipient stage of every variety of pul- monary consumption, our constant object should be to counteract the inflammatory diathesis of the system, and to remove all sources of irritation. The regimen must be strictly antiphlogistic. In gene- ral, vegetable and farinaceous diet, with milk, is the only proper nourishment for a patient labouring under incipient phthisis. The system in all phthisical habits is peculiarly excitable, and readily thrown into a state of general and injurious irritation by even weak exciting causes. It would be in vain to expect a reduction of the local pulmonary irritation, so long as the system generally is in a state of preternatural excitation. In conjunction with a mild, unir- ritating diet, the wearing of flannel next the skin, and the careful avoidance of inclement and variable weather, gentle exercise, either by walking, riding on horseback, or in an open carriage, when the air is mild and uniform, will tend to invigorate the system, and les- sen its morbid irritability. Bleeding is highly recommended by some in the early period of phthisis pulmonalis; and when cautiously employed in cases attended with an evident inflammatory condition of the general system, its effects are often beneficial. To draw blood copiously, or very fre- quently, however, would, in most instances, prove injurious by in- 360 PHTHISIS PULMONALIS. creasing the debility and morbid excitability of the system. The abstraction of blood by cupping or leeching, in cases which indicate the propriety of direct depletion, will in general answer all the pur- poses, which can be expected from this measure. To expect to effect the permanent reduction of the quickness, tension, and fre- quency of the pulse by venesection, is a fallacious hope. The sys- tem in this disease is preternaturally excitable or irritable; and in order to reduce the velocity and momentum of the circulation, measures must be employed which tend to subdue this morbid irri- tability, an effect which cannot be obtained from venesection. To accomplish this purpose, we possess no remedies which are so safe and so effectual as digitalis, and small doses of tartar emetic. The former of these articles has a powerful tendency to diminish the excitability of the heart and arteries, and consequently the velocity of the circulation. Much diversity of opinion has been expressed in relation to the value of this medicine in consumptive affections. My own observations have led me to the conviction, that under careful management, and in conjunction with a well regulated diet, and proper attention to the cutaneous functions, much good may be derived from its employment in incipient phthisis. Its salutary operation would seem to depend on its power of lessening the activity of the heart and arteries, and thereby moderating the mo- mentum of the circulation, and consequently the general and local irritated condition of the disease. Among the most important remedies we possess in the early pe- riods of phthisis, are such as operate through the medium of the skin, or such as establish a regular determination to the external surface of the body. Blisters, issues, or setons, can never be pro- perly omitted in incipient consumption. I have repeatedly known the insertion of a caustic issue or a seton on the chest, to remove every symptom of approaching consumption. Even in cases com- pletely developed, counter-irritation, in any of these modes, will generally aid very materially in retarding the progress of the malady. I am disposed to ascribe more remediate power in this affection to setons and issues than to blistering, and of these two, I generally prefer the latter. Pustulation with tartar emetic, or with the white precipitate oint- ment, is also a very efficient mode of counter-irritation in this dis- ease. I have seen much benefit derived from both these applications in its incipient stage. When the pustules are formed, emollient poultices should be applied to them, and renewed two or three times daily, until they are healed. Whatever counter-irritating measure be adopted, it should be regularly persevered in, until all the threat- ening symptoms have entirely disappeared, or its manifest ineffi- ciency be ascertained. To aid the effects of flannel next the skin, and of a warm and equable temperature in maintaining a regular action of the cutaneous exhalents, advantage may be derived from the use of small portions PHTHISIS PULMONALIS. 361 of tartar emetic dissolved in some mild diluent beverage, in the commencement of the disease. A grain or a grain and a half of this antimonial may be dissolved in a pint of gum arabic water, and drank during the day. M. Lenthois of Montpelier, speaks strongly in favour of this remedy in phthisis. His mode of employing it is as follows:—A grain of tartar emetic is to be dissolved in eight table-spoonfuls of water; this is to be mixed with four quarts of water, or a table-spoonful to the pint, which the patient is directed to use for his common drink at meals, and at all seasons and hours. Dr. Armstrong directs the use of this article in doses sufficiently large to excite nausea, and occasionally vomiting. " I suspect," he says, " that if a regulated temperature and the exhibition of tartarized antimony»were more early and perseveringly employed than they usually are, our success in preventing the development of phthisis might be much greater than it commonly is." The account which Lenthois gives of the usefulness of tart, antim. in the present affec- tion is certainly exaggerated; but, although not perhaps of itself sufficient to arrest the progress of incipient phthisis, it deserves, nevertheless, very considerable attention as an auxiliary means. The employment of emetics in this disease was formerly much recommended by some writers. Dr. Maryatt gave the sulphate of copper and tartar emetic in doses of from two to five grains of the former with two grains of the latter twice a week, without allowing the patient any kind of drink for several hours afterwards. Dr. Senter advises to give the blue vitriol in conjunction with ipecacu- anha (seven grains of each) in the morning before receiving any thing into the stomach, and withholding all kinds of drink for some time afterwards. Unquestionably, however, the most efficient of all measures for counteracting the tendency to phthisis, or arresting its development or progress, is a removal to, and residence in, a mild, genial, uniform, and salubrious climate. The influence of such an atmosphere, aided by proper diet, regular and gentle exercise, and external revulsives, with an attention to the hepatic and intestinal functions, will do all, perhaps, that remediate treatment is capable of effecting towards permanently arresting the progress of the disease in its incipient stage. The climates of Naples, of Nice, of Florence, and of Rome, and lately of Egypt, as well as of some of the south- ern parts of France and Spain, have been particularly recommended to consumptive invalids. Nothing, however, is to be expected from the influence of a warm climate after the disease is once fully deve- loped. It is only in the incipient stage of the complaint that any permanent advantages can be obtained from this source, in scro- fulous phthisis.* * See Dr. Carter's " Remarks upon the Effects of a Warm Climate in Pulmo- nary Consumption and some other Diseases."—Medico-Chirurg. Transact, vol. vi.—See also, Medical History of the British army in Spain__Medico-Chirurg. Transact, vol. vi. Vol. I.--46 362 PHTHISIS PULMONALIS. Upon the foregoirtg remediate measures—namely, occasional small bleedings, external irritating applications, antimonials, a regulated temperature, a simple unirritating diet, and exercise by walking or gestation, our hopes must be mainly placed in our efforts to arrest the disease in its incipient stage. A variety of other remedies have, however, been recommended in this affection; and of these,prussic acid has of late years attracted the greatest attention. Could the dose be regulated with any degree of certainty, so as to procure its influence without the risk of dangerous prostration, advantage might, no doubt, be derived from its employment. Possessing, as it does, a direct and most powerful tendency to subdue the irritability and sen- sibility of the system, it would seem to be peculiarly calculated to do good in the present affection, in which a particularly excitable con- dition is so conspicuous. When the disease is once completely established, and purulent ex- pectoration with hectic fever has supervened, we can no longer hope to procure a favourable issue by remediate management; and all our efforts must be directed to the palliation of the symptoms and the prolongation of its course. With the exception of depletion, the remedies already mentioned as most apt to arrest incipient con- sumption or prevent its development, are also among the most useful means in retarding its progress when fully established. When the system is much exhausted in the confirmed stage of the disease, tonics are commonly resorted to, but although I have tried them often in scrofulous phthisis, I do not remember having ever de- rived any obvious advantage from them—but most commonly, they increased the general irritation.* Where it becomes necessary to support the strength of the system, we may allow a more nourishing diet, particularly the more digestible and nourishing kinds of meat —such as tender beef-steak or mutton. To check the profuse and exhausting night sweats which occur in the advanced periods of the disease, I know of no remedy which is so effectual as the acetate of lead. I have frequently prescribed this. article with unequivocal benefit in this respect. Four or five grains of the acetate may be taken in the evening. I have known some patients who, after having experienced the relief which it frequently procures, would not do without it. The best mode of giving it is in union with opium. Some of the mineral acids are also recom- mended for this purpose. Of these, the diluted sulphuric acid, or elixir of vitriol is the best. Opium is a highly valuable palliative in the advanced stage of phthisis. It generally allays, for a time, the violence and frequency of the cough; tends to diminish the night * The tonics most commonly employed in phthisis pulmonalis, are the mistura feri compos., the quinine, and particularly Dr. Griffith's mixture,—thus: R. Myrrh, ^i. terendo mortario cum spirit, piment. ^vi. aq. distil. Jviss. dein adde subcarbon. potassse £ss. sulphat. ferri. gr. xii. syrup, gii.—M. Take ^ii. four times daily. PHTHISIS PULMONALIS. 363 sweats, as well as the general feelings of distress, illness, and dis- comfort; and at last, assuages the pangs of approaching dissolution by its soothing and oblivious effects on the nervous system. When opium produces disagreeable effects from idiosyncracy, the lactuca- rium may be used in two or three, grain doses with excellent effect. We may also employ Dover's powder in union with the extract of hyoscyamus as an anodyne palliative, where opium by itself is ob- jectionable. Six grains of the former, with three grains of the latter, may be given every night. Dr. Bourne, professor of the practice of physic in the university of Oxford, speaks strongly in favour of the employment of uva ursi in consumption. He asserts, that he cured nine cases out of sixteen, by the use of ten grains of uva ursi with one-third of a grain of opium three times daily. In consumptive symptoms from chronic bronchitis, I have derived much benefit from these two articles given in combination; and the cases related by Mr. Bourne, were probably of this kind.* Expectorants are sometimes useful to palliate the cough. Flax- seed-tea, decoction of the lychen icelandicus, solution of gum arabic, infusion of tussilago or of marshmallows, the camphorated tincture of opium, and syrup of squills in equal proportions, or syrup of poppies with-tincture of tolutan, may be used for this pur- pose. Small doses of opium and tartar emetic, as recommended by Pariset, will generally answer very well.t The inhalation of tar-fumes is not adapted to the treatment of tubercular consumption. In the catarrhal variety of the disease, much benefit may be occasionally derived from this and similar in- halations. Nor is mercury a remedy calculated to do good in the present form of phthisis, although much recommended by some practitioners. The cases of consumption which are reported as having yielded to ptyalism were, no doubt, dependent on chronic mucous inflammation, unconnected with a strumous habit or tuber- cles in the lungs. Too little discrimination was formerly made be- tween the different varieties of pulmonary disease attended with consumptive symptoms; and it is to this circumstance that we may ascribe the discordant and contradictory statements that have been published in relation to the effects of different remedies and modes of treatment. Laryngeal and tracheal phthisis appear frequently to commence with an obscure inflammation in some part of the larynx or trachea, which may continue for months before ulceration occurs. This in- * Cases of Consumption, &c. healed by uva ursi, &c. By Dr. Bourne, Lon- don, 1806. X R«—G. opii gr. x. Tart, antim. gr. iv. Conserv. rosar. q. s.—M. Divide into forty pills. S. Take one every four hours. 364 * NEPHRITIS. cipient stage is characterized by more or less hoarseness, change of voice, and disturbed respiration; and it is only during this early pe- riod of the disease, before ulceration has taken place, that any de- cided and permanent benefit can be derived from remediate treat- ment. Whenever,, therefore, we find hoarseness of voice, with cough, disturbed respiration, and a slight prickling pain in the larynx or trachea to continue for some time, particularly when there is no reason to ascribe these symptoms to common cold, we ought imme- ttely to adopt the most active measures for the removal of the action. Should ulceration not have taken place, we may, per- haps, succeed in preventing it, and in saving the life of the pa- tient. (Armstrong.) One of the most indispensable curative means is a mild and uniform temperature. On no account should the pa- tient be suffered to expose himself to a cold or humid atmosphere. While these precautions are observed, blisters should be applied to the throat, and the blistered surface kept discharging by irritating dressings. Armstrong recommends the use of balsam copaiba in the early stage of this variety of the disease. In several cases which have lately come under my care, the use of the muriate of ammonia, according to the formula mentioned at page 127 of this work, ap- peared to do much good. When the disease arises from syphilis, mercury may be regarded as the principal remedy in conjunction with a regulated temperature and blistering. In consumptive symptoms from chronic pleuritis, our principal reliance must be placed on external irritating applications to the chest, the use of calomel so as to produce gentle ptyalism, and diure- tic medicines. Blisters or tartar emetic ointment should be repeat- edly applied so as to keep up a constant irritation on the external surface of the chest. Internally, we may give calomel and squills in combination, with a view both to a general mercurial impression and the production of diuresis. CHAPTER XIII. OF THE PHLEGMASIA OF THE URINARY AND GENITAL ORGANS. Sect. I.—Nephritis.—Inflammation of the Kidneys. The symptoms which characterize acute inflammation of the kid- neys, are not in general obscure or equivocal—being usually readily distinguished from those of other painful affections seated in the neighbourhood of these organs. When this affection is excited by cold, it commences commonly like other diseases from this cause, NEPHRITIS. 365 by slight chills and flushes of heat—the febrile reaction preceding the occurrence of pain in the "loins. When the disease proceeds from contusions, strains, and irritation of renal calculi, cantharides, or other irritating substances absorbed into the circulation, or from metastasis of gout and rheumatism, the first intimation of its occur- rence is an acute pressing pain in the right or left lumbar region, or in both. The pain* is deep-seated and of a very severe aching character, and but very little aggravated by external pressure. Any sudden concussive motion of the body, however, always increases the pain considerably. The pain often darts down along the ure- ters,—the testicle of the affected side is retracted towards the ab- dominal ring, and a sense of numbness is experienced in the thigh. Nausea and vomiting occur in most cases, and violent colic pains in some. The bowels are torpid; the urine is very small in quantity, high-coloured, sometimes tinged with blood; and the desire to void it is frequent, urgent, and troublesome. When both kidneys are inflamed, the secretion of urine is generally almost entirely sup- pressed;—this, indeed, happens sometimes when the inflammation is seated but in one kidney, the other having its functions disturbed sympathetically, t The patient is easiest when he inclines his body towards the affected side, so as to take off the tension of the lumbar muscles. When in bed, he lies either on the affected side or on the back, with the body inclined towards this side. In some instances, a dull heavy pain is at first felt low down, seemingly where the ureters enter the bladder, and afterwards passes slowly up along the ureter until it reaches the kidney, where it becomes stationary. The pulse in nephritis is full, hard, and frequent, in the early period of the affection; but after the second or third day, it generally becomes smaller and more frequent, particularly where much nausea and vomiting occur. The surface is above the natural standard of tem- perature, and usually very dry and parched. Diagnosis.—From inflammation of the psoas muscle, nephritis may be distinguished by the pain in the former affection being * W. Bouillaud asserts, contrary to the general statement of pathologists, that pain does not always attend renal inflammation. t This is always a very unfavourable occurrence. Total or almost entire sup- pression of the urinary secretion can never continue long in any affection, with- out adding greatly to the danger of the disease. Complete ischuria renalis, even without the irritation of local inflammation, seldom continues beyond four or five days without producing fatal oppression of the brain.—(Sir H. Halford, Transactions of the College of Physicians of London, vol. vi.) There is a case mentioned, however, by Dr. Laing, in vol. x. of the Edin. Med. and Surg. Jour- nal, where the secretion of urine was suspended for nine days without terminat- ing fatally. The great danger of suppression from this secretion in nephritis, was long ago noticed by Aretaeu3.—De Causis et signis Morborum, acut. lib. ii. cap. ix. p. 22. 366 NEPHRITIS. always considerably increased on bending the body forwards, where- as, in the latter disease, this position generally lessens the pain. Ne- phritis is usually attended with more or less nausea and vomiting, and frequent desire to pass off urine, which is not the case in psoas inflam- mation, unless the kidneys become affected at the same time. From lumbago, nephritis is distinguished by the paucity of the urine, the disury, the nausea and vomiting, the pain shooting down the ureters in the latter affection; and by the great increase of pain on assuming the erect position, or by any motion of the muscles of the loins in the former, whilst in the latter, little or no increase of pain occurs from these causes. Nephritis is generally rapid in its course. It seldom continues beyond the seventh day without terminating in resolution or tending to suppuration. When the disease is about terminating favourably by resolution, the fever and pain decline; the skin becomes uniformly moist; the urine is copious, turbid, or charged with mucus; and the nausea and vomiting cease.* The symptoms which denote occur- rence of suppuration are—frequent chills or shiverings; a dull, heavy throbbing, instead of the preceding acute pain in the kidney; a slight abatement of the febrile symptoms; and a feeling of heaviness or numbness in the affected part. In some instances, the abscess bursts into the pelvis of the kidneys and is then discharged with the urine. This is not so favourable an oc- currence as might at first sight appear. I have known purulent matter discharged with the urine for upwards of nine months, from a renal abscess. In some instances, more or less pus is discharged with the urine for several years—producing at last hectic and great emaciation, or what has been called tabes renalis. A puruloid substance in the urine must not, however, be too hastily pronounced as the result of renal suppuration, or as genuine pus. The irritation of a calculous concretion in the kidneys, will sometimes give rise to a secretion resembling pus; and the same discharge may occur from subacute inflammation of the'neck of the bladder. Genuine pus in the urine may generally be distinguished from a puruloid fluid mixed with this secretion, by the former sinking down and forming a thin uniform layer along the bottom of the vessel in which the urine is left stand- ing; whereas, the latter substance remains partly suspended in the urine, and does not settle down into a close layer along the bottom of the vessel.t * Aetius says that a watery and pellucid urine, indicates a slow and difficult declension of the disease—aquosae autem mictiones, et purse ac pellucentes regre morbum secerni indicant.—Sermo. xi. cap. xvi. t Van Swieten observes, when the matter comes from the bladder, there is discharged with the urine a sort of foliaceous fragments; but when it proceeds from suppuration in the kidneys, it is more uniformly mixed with the urine.— Comment, vol. x. p. 38. NEPHRITIS. 367 In some cases, the abscess points externally, and may be evacuated by an incision into the soft fluctuating tumour. Cases are on record which terminated favourably after the matter had obtained exit in this way; but in many instances of this kind, a fistulous opening re- mains, which it is always extremely difficult and sometimes impos- sible to heal—the patient gradually sinking under symptoms of hectic. * Authors mention instances of renal abscesses having opened into the intestines; and Richter states, that the matter has found its way into the liver and even into the cavity of the thorax.t Renal abscess has also been known to burst into the cavity of the abdomen, giving rise to rapid and fatal peritonitis;J and instances have occur- red, in which the matter has passed down along the psoas muscle, and pointed at the upper part of the thigh, like psoas abscess. Inflammation of the kidneys, occasionally, though rarely, termi- nates in gangrene. Scirrhus, or induration of the kidneys, also, sometimes results from this affection. Bonetus relates several exam- ples of this kind.§ M. Bouillaud mentions a change of the paren- chymatous substance of the kidneys into a tuberculous or encepha- loid matter, as the result of renal inflammation; and in several cases he found the structure of this organ converted into a yellowish seba- ceous matter. || Causes.—From the intimate relation which exists between the kidneys and the skin, cold becomes a very frequent cause of this affection. In many instances, it arises from causes acting directly upon the kidneys—such as irritating diuretics, cantharides, turpen- tine, renal calculi or gravel, contusions, strains, &c; and in persons subject to gout or rheumatism, the disease sometimes occurs, rapidly and violently, in consequence of metastasis of these affections. Treatment.—As in all other phlegmasial affections, prompt and efficient blood-letting constitutes the primary remedy in this disease. In addition to general bleeding, leeching, or what appears to be bet- ter, cupping over the lumbar region must not be neglected. Active purgatives also assist materially in reducing the local inflammation. Six or eight grains of calomel, followed in three or four hours by a full dose of castor oil, or three or four pills of the formula given below, will generally answer this purpose well. IT The bowels must be kept in a loose state by the daily administration of aperients; or by laxative enemata throughout the whole course of the disease. * Hie autem morbus molestus est ex eoque plures ad renum tabem devenimjt. Hippocrates, De Intern. Affect, cap. xvi. | Specielle Therapie, b. i. p. 615. X Vogel. Handb. t. iv. p. 398.—Richter, Sp. Therap. § Sepulchret. Anat. torn. ii.—as quoted by Morgagni. || Observations on the Anatomy and Diseases of the Kidneys, &c. By J. Bouil- laud.—Journal Complementaire. TT R.—Extract, colocynth. compos. Qi. Calomel gr. xii.—M. Divide into six pills. 368 NEPHRITIS. Much relief will sometimes be obtained from anodyne emollient injections, particularly in the evening, after the free operation of a purgative. Indeed, the assiduous employment of soothing emollient enemata, either with or without laudanum, is always a most useful auxiliary in the treatment of this affection. For this,purpose we may use an infusion of flaxseed, or simply warm water mixed with a portion of milk; or a thin decoction of barley. Fomentations to the external lumbar region will likewise be proper, particularly in the early period of the disease, immediately after leeching or cup- ping has been practised. A large emollient poultice is a more con- venient, and probably a better application for this purpose. Blisters are very generally regarded as objectionable in this affection, on account of the tendency of cantharides to irritate the urinary organs when absorbed into the circulation. I have nevertheless derived decided benefit from blistering the region of the inflamed kidney, without having ever known any injurious consequences resulting from it. By suffering the vesicatory to remain no longer than is necessary to inflame the skin—which is seldom more than four or five hours, and then applying an emollient poultice, a full blister will be raised; and I have never known strangury to occur where this mode of vesicating was adopted. I have pursued this practice in ten or twelve cases of nephritis, and generally with evident ad- vantage. Sinapisms may also be used, after adequate depletion, with a prospect of benefit; but they are not equal, in efficacy, to blisters, in this as in other internal inflammations. From the close sympathy which exists between the skin and the kidneys, considerable benefit usually arises from the employment of suitable diaphoretics in this affection. Where the stomach is not too irritable, antimonials* maybe employed; but where much nausea and vomiting attend, it will be better to depend on the use of the warm bath, more especially the steam-bath, for the production of diaphoresis. Hot bricks, wrapped in flannels previously moistened with vinegar and water, and laid under the bed-coverings near the patient's body, seldom fail to bring on a more or less copious and uniform perspiration. The nitrate of potash cannot be used with propriety in nephritis, on account of its tendency to excite the activity of the kidneys, an effect which could hardly fail to do mis- chief in the inflamed state of these organs. All stimulating diure- tics indeed must be carefully avoided—copious draughts of muci- * R.—Spir. nit. dulc. Ji. Vin. antimonii gii. Tinct. opii gr. xxx.—M. S. Take a tea-spoonful every hour or two. Or,—R.—Spirit mindereri §iv. Tart, antimonii gr. i. Spir. nit. dulc. gii. Syrup limonis ^ii. Tinct. opii gr. xxx.—M. S. Take a table-spoonful every two hours. CYSTITIS. 369 bginous diluents being the only proper means for promoting the urinary secretion. After the inflammatory condition of the system has been in some degree subdued by the antiphlogistic measures already mentioned, small doses of Dover's powder repeated every three or four hours, will tend to keep up a general diaphoresis, as well as to moderate the local pain and general irritable state of the system. Much relief may also be derived after proper depletion and purging, from the occasional use of anodyne enemata.* A slight sensation of pain and soreness is apt to remain in the affect- ed kidney for several days, and sometimes weeks, after the disease has been subdued. Here uva ursi, in conjunction with small doses of opium or Dover's powder, is the best remedy. From twenty to thirty grains of the uva ursi, with the fourth of a grain of opium, or three grains of Dover's powder, may be taken four times daily. This remedy is no less useful in cases where the inflammation has terminated in suppuration. I have known the extract of conium, with an infusion of uva ursi, to be employed in suppuration of the kidney with complete success. Three grains of the extract were taken three times daily, and a wine-glassfu4 of the infusion (one ounce of the uva ursi to a pint of water) every four hours. Minute doses of muriate of mercury with this extract,! have also been found beneficial in abscess of the kidneys. The use of lime water, to the extent of from four to six ounces daily, has been recommended in suppuration of the kidneys. (Richter.) Decided benefit has also been derived from the balsam copaiva; but this article must be avoided as long as there is any evidence of inflammatory action pre- sent. Sect. II.—Cystitis.—Inflammation of the Bladder. Symptoms.—Violent burning, lancinating, or throbbing pain in the region of the bladder—extending to the perinaeum, and in some instances to the testicles and the upper part of the thighs; attended generally with a sense of constriction in the hypogastric region. The pain is greatly increased by pressure made immediately above the pubis, and the perinaeum feels sore to the touch. There are fre- quent, but often ineffectual efforts to void urine, more or less stran- gury or dysury being usually present. The small portion of urine * R.—Pulv. opii gr. ii. Mucilag. g. arab. ^ss. Lactis. tepefact. §v. Or,— R—Tinct. opii 3i. Infusi. lini. gvi__M. ft. enema. This injection may be repeated two or three times daily. X R.—Muriat. hydrarg. gr. vi. Extract, conii maculat. ^iss.—M. Divide into forty-five pills. S. Take one every morning, noon, and evening. Vol. I. —47 370 CYSTITIS. which passes off' is deep red, and often tinged with blood. In some cases there is a constant stilicidium of urine. Nausea and vomit- ing, with great anxiety in the praecordia, are seldom absent in this affection. The bowels are constipated, and there is often a sensation of tenesmus, from the inflammation extending to the lower part of the rectum. The pulse is full, hard, and frequent; the skin hot and dry; the thirst urgent, and the patient is restless and dejected. If the disease continues unchecked in its course, more or less swelling occurs in the loins, with increased tenderness in the hypogastrium and perinaeum. Some diversity occurs in the symptoms, according to the particular part of the bladder in which the inflammation chiefly exists. When the neck of the bladder is inflamed, great pain is felt in the perinaeum, and total retention of urine sometimes oc- curs, or the patient is tormented with dysury or incessant feelings of strangury. In this case, the introduction of a catheter or bou- gie causes extreme suffering. " When the posterior part of the bladder is affected, the rectum suffers more particularly, and the pa- tient is harassed by a most distressing and constant tenesmus. Some- times the inflammation occupies that part of the bladder in which the mouths of the ureters are situated, which thus become involved in the affection, and a suppression of urine, more or less complete, and its consequences, take place; in this case, there is commonly more or less pain and tenderness on pressure in the hypogastric region." (Prout.) Like other inflammations, cystitis terminates either in resolution, suppuration, gangrene, or induration and thickening of the coats of the bladder. Resolution, besides the abatement of the pain and fe- ver, is attended with general and uniform diaphoresis; a turbid and rather copious urine, passed with little or no pain; and ability to bear pressure on the epigastrium and perinaeum. On dissection, the inner membrane of the bladder is, generally, found minutely injected, so as to give a uniform red appearance to the whole surface. In some instances, the inflammation is confined entirely to the internal coat; in others, it extends to the muscular tunic; and sometimes even to the peritoneal covering.* Suppuration is not a frequent termination of this affection. (Richter.) Abatement of the violence of the fever and pain, accom- panied with chills or rigours, and the sudden appearance of a white matter in the urine, indicate the occurrence of suppuration. In some instances, abscesses are formed in the coats of the bladder, particu- larly near its neck; and in others, the abscess forms in the cellular structure surrounding the neck of the bladder. When suppuration occurs in the mucous membrane, or when the abscess between the tunics of the bladder bursts into its cavity, the matter will be dis- charged with the urine. Sometimes the abscess points externally, and may open into the rectum or vagina, or sink down and infiltrate * Wilson on the Urinary Organs, p. 297. CYSTITIS. 371 into the cellular membrane of the pelvis. The abscess has also been known to burst into the cavity of the peritoneum; and the matter has made its way into the labia pudendi, and the loose structure of the scrotum. In some cases, the coats of the bladder are thickened and indurated, particularly the.internal one. Sometimes fungoid elevations of the mucous membrane occur; at others, indurations are found in different parts, resembling small scirrhous tumours, and some of these are occasionally ulcerated. Firm adhesions have been noticed between the bladder and rectum, as well as between the bladder and uterus, in consequence of acute cystitis. It is sometimes very difficult to distinguish some of these results of inflammation of the bladder dur- ing life from calculus. / Gangrene is a frequent termination of cystitis. The majority of instances that prove fatal within the first six or seven days, terminate in gangrene. The occurrence of gangrene is announced by the sudden cessation of the pain; cold extremities; profuse and clammy perspi- ration; great prostration of strength; a cadaverous expression of the countenance; slight confusion of the mind; a small, frequent, and weak pulse; and hiccough. Causes.—Cystitis may be produced by mechanical irritating sub- stances in the bladder; retained urine; external injuries on the hypo- gastric region; irritation from acrid substances absorbed and conveyed to the bladder—as cantharides, turpentine, &c; metastasis of gout and rheumatism; irritating injections forced into the bladder; irrita- tion from the introduction of a bougie, or catheter; gonorrhoea; sup- pression of haemorrhoidal discharge, and of perspiration; cold ap- plied to the feet or lower portion of the abdomen; injury sustained in parturition, or from the use of obstetrical instruments. Treatment.—Acute cystitis is a rapid and highly dangerous affec- tion, and must be promptly met with the most efficient antiphlogistic measures. Efficient blood-letting must be early practised, until the activity of the pulse is moderated. After general bleeding, leeching is of the utmost importance in this affection. The leeches must be applied to the perinaeum, about the anus, and to the hypogastric re- gion; and, when the pulse admits of it, they should be reapplied. Immediately after leeching, an emollient poultice should be applied over the hypogastrium, pubis, and perinaeum. The bowels must be kept open, by gentle laxatives and mucilaginous enemata. Much relief is commonly obtained from an emollient anodyne enema, im- mediately after the rectum has been emptied by a laxative. Atten- tion must be early paid to the evacuation of the urine, should the bladder be found distended by it. Great care, however, is required to avoid all unnecessary irritation from the introduction of the cathe- ter. When the neck of the bladder is inflamed, the pain caused by this operation is generally extremely severe, and it is sometimes im- possible to reach the bladder, from the great irritability and spas- modic contraction of its neck. This can, in some degree, be obvi- 372 CHRONIC CYSTITIS. ated by introducing three or four grains of opium into the rectum an hour before the catheter, is used, accompanied with an efficient abstraction of blood, both by venesection and leeching. To promote the action of the cutaneous exhalents, we may employ the warm bath; or, what is better, the steam-bath, as mentioned under the head of nephritis. Some of the milder diaphoretics, such .as spiritus men- dereri, diluted with barley-water or flaxseed tea; or small and fre- quent doses of pulvis antimonialis, or of Dover's powders, may be usefully exhibited, with a similar view. The hip-bath is particu- larly recommended by Richter as a local application in this affec- tion. After the violence of the local and general inflammatory action has been moderated by the foregoing means, much benefit may sometimes be derived from the internal use of opium and calomel. Richter observes, that opium is a primary remedy in cystitis, par- ticularly when given in union with mercury. Prout also recom- mends the internal use of this combination. A grain of opium, with two grains of calomel, may be given every, four hours. In cases of a subacute character, the employment of opium and calomel, in conjunction with leeching, emollient anodyne injections, and fomen- tations or poultices to the hypogastrium and perinaeum, is particu- larly beneficial. Nitre and blisters are apt to increase the local irri- tation, and cannot, therefore, be resorted to without considerable risk of doing injury. " If blisters be employed," says Prout, " they should be used with caution and permitted to remain only for a short time, and afterwards such dressings applied as tend to keep them open." The mode of blistering mentioned, when speaking of the treatment of nephritis, may, perhaps, be safely adopted in this affec- tion. Considerable advantage is said to accrue from the repeated injection of mucilaginous fluids into the bladder, by obtunding the acrimony of the urine, and soothing irritation. Sect. III.—Chronic Cystitis. Chronic inflammation of the inner membrane of the bladder is not an uncommon affection, and is generally described under the name of cystirrhoza. In some instances, this affection is the consequence of acute cystitis; but it may arise, at once, from the action of the same causes which produce acute inflammation of the bladder. The symptoms which accompany chronic mucous inflammation of the bladder, are—slight lancinating pains, attended with a sense of heat or burning in the region of the bladder, and a feeling of weight and tenderness in the perinaeum; frequent and harassing desire to pass urine, with occasional spasmodic action of the bladder and urethra. The urine is loaded with more or less of a tenacious mucus. Slow fever generally attends, accompanied with thirst, general debility, " particularly about the back and loins," and, in protracted cases, much emaciation, and exhaustion. There is generally considerable derangement of the digestive functions; loss of appetite; sometimes CHRONIC CYSTITIS. 373 nausea and vomiting; costiveness; tongue covered with a white or brown fur; and the skin is harsh and dry. " In slight and incipient cases of this affection, the urine, when first passed, generally appears of a whitish colour, and is more or less opaque and turbid, with the appearance of flocculi floating through it. On standing, however, for some time, it becomes more or less transparent, and the mucus will be found together in a mass at the bottom of the vessel." (Prout.) The writer just quoted states, that in most cases the urine is acid; others assert, that it, commonly, exhales an ammoniacal odour, and that it is rarely acid. In some cases, the quantity of mucus dis- charged, with the urine," is enormous, amounting, occasionally, to several pints in the day; and in this case it not only comes away diffused through the urine, but also in the form of large coagula, which, by blocking up the urethra, give origin to the most distress- ing symptoms—particularly to a sense of severe burning pain along the whole course of the urethra." Sometimes this mucus is easily diffused in water or the urine; but in inveterate and violent cases, it is so extremely tenacious, as to make it very difficult to mix it with the urine. When suffered to cool, the mucus, says Prout, is sometimes so tenacious " that it may be drawn into strings of consi- derable length, and the vessel may be frequently inverted without its falling out." In the worst cases, particularly when ulceration of the inner surface of the bladder exists, copious discharges of blood, at times, take place. I have known an instance of this disease, which continued for five or six years, and at last terminated fatally, from the supervention of acute inflammation in consequence of irri- tating injections. In this case, more or less haemorrhage occurred from the bladder almost every month. The discharge of mucus was always very considerable. On dissection, two large ulcers of the mucous membrane were found near the neck of the bladder. Dr. M'Dowell found, in this affection, the mucous surface of the bladder to present "different degrees of vascularity, from merely a few patches of a dark or bright red colour, to an entire vascularity, in some cases so marked, as to appear as if the bladder had been daubed over with blood; the veins in general are turgid; the membrane much thickened; frequently numerous ulcers occur, covered with a tenacious brownish coloured lymph; these are sometimes deep and numerous, so as to give a honey-comb appearance to the membrane. The inflammation sometimes ends in complete sphacelus of the interior of the bladder."* " Blood," says Dr. M'D., " is often dis- charged in very large quantity; and, together with the abundant mucus, a white powdery sediment, or sanious matter, is mixed with the urine." This affection is most apt to occur in old and gouty subjects; and persons of an irritable and scrofulous habit are said to be particularly predisposed to it, " more especially if they have been accustomed to * Dublin Transactions, vol. iv. 374 CHRONIC CYSTITIS. free living, or been given to venereal excesses, or have suffered from these affections or gout." Treatment.—In the early stages of the complaint, we must endea- vour to reduce the chronic inflammation by local, depleting, and counter-irritating measures. Cupping along the loins, with the occa- sional application of leeches to the perinaeum, and about the anus, may be accounted our most efficient remedies during the first period of the disease. If the pulse is active, and the pain in the pelvis con- siderable, general blood-letting may be very beneficially resorted to. The bowels must be kept in a relaxed state by the occasional use of gentle purgatives, such as castor oil, or magnesia. I have known much "benefit to result from a-caustie issue on the upper and inner part of the thigh. Advantage would probably be derived also from frictions and pustulation with tartar emetic ointment on the upper part of the thighs, or on the loins. When the inflammatory symp- toms have subsided, either in consequence of the application of the remedies just stated, or by the long continuance of the disease, astringents, with some of the narcotic extracts, may be resorted to with a prospect of advantage. Dr. Prout prefers the uva ursi to all other articles of the astringent kind in this affection. " Given in combination with hyoscyamus, and steadily persevered in for a con- siderable time, the uva ursi seldom fails to diminish the irritation and quantity of mucus, and thus to mitigate the patient's sufferings." Within the last five or six years, the buchu leaves (diosma crenata,) have been strongly recommended to the profession as a valuable remedy in this and other chronic affections of the bladder. Dr. M'Dowell employed it successfully in three cases, according to the following formula: R.—Infus. buchu §vii. Tinct. ejusdem. -----cubebae aa §i.—M. S. Take an ounce of this mixture three times daily. The use of this remedy should be continued for three or four months. I have heard of the successful employment of an infusion of the pipsissewa, (chimaphila umbellata,) in a case of this disease. In se- veral inveterate cases I have prescribed the muriated tincture of iron, with infusion of peach-leaves, with very manifest benefit. In one instance, a perfect cure was effected by the tincture of iron, in conjunction with uva ursi. Frictions over the groins and the hypo- gastrium with camphorated oil has appeared to me serviceable in some cases. Besides these, a great variety of other remedies have been recommended for the cure of this affection. Balsam copaiva; turpentine; balsam peru; camphor; madder; and many of the ve- getable astringents are mentioned by writers as often beneficial in this complaint. From the known good effects of balsam copaiva in chronic inflammation of mucous membranes, there is some reason to presume that advantage might be obtained from its use in this com- HYSTERITIS. 375 plaint Experience does not, however, furnish us with much testi- mony in its favour. I have given it in a few cases, but in these it appeared to give additional uneasiness in the bladder, without dimi- nishing the mucous discharge. Different kinds of injections into the bladder have also been re- commended as beneficial in this affection; such as flaxseed tea; infu- sion of marsh-mallows; or barley-water. When retention of the urine occurs from a spasmodic constriction of the neck of the blad- der, relief will often be obtained from seven or eight drops of the muriated tincture of iron given every half hour. The diet should be simple and digestible, and every kind of stimulating beverage carefully avoided. Fatiguing exercise, or riding on horseback, or in a carriage over rough roads, usually aggravates the symptoms. The drink should be bland and mucilaginous. One patient under my care, always felt himself much relieved by drinking the infusion of the malva rotundifolia, a common plant in this country. I have also prescribed the constant use of slippery elm bark tea with bene- ficial effect. Sect. IV.—Hysteritis.—Inflammation of the Womb. Acute inflammation of the uterus, generally occurs in the puerpe- ral state, and usually within a few days after parturition. Sometimes this affection commences with rigours, succeeded by fever, before any pain is experienced in the uterus; and at others, more or less severe pain in the region of the uterus is the first intimation of its occur- rence. The characteristic symptoms of the disease are: a fixed^ con- tinuous, lancinating, or a dull and aching pain in the pelvis, greatly increased by pressure or motion, and accompanied with a sense of weight or bearing down in the perinaeum. The urine is generally passed with much pain and difficulty, and in some cases a total re- tention takes place. This is particularly apt to be the case when the anterior and lower portion of the womb is inflamed. When the in- flammation is chiefly located in the posterior part of the uterus, the pain is particularly severe in the region of the sacrum, and the pa- tient experiences much pain, and often tenesmus, in evacuating the bowels. Sometimes the pains extend to the iliac regions, to the hips, and down the thighs to the knees, and even to the feet. When the pains extend to these parts, the lateral portions of the womb are usually the principal seat of the inflammation. In the early period of the disease, little or no swelling of the ab- domen occurs, but on examining the pubic region externally with the hand, the uterus is always found considerably enlarged, firm, and exceedingly tender to the touch. In those cases that occur soon after delivery,the paininthepelvisgenerally becomes much increased, at times, in consequence of the occasional contraction of the uterus, and may be mistaken for severe after-pains. To distinguish the in- flammatory pains from the latter, however, it is only necessary to 376 HYSTERITIS. bear in mind, that the former are always continuous, though occa- sionally aggravated, whereas the after-pains are intermitting. In the majority of instances, the system generally sympathizes strongly with the inflamed organ. In the early period of the dis- ease, nausea, with occasional vomiting, occurs;*—the pulse, in some cases, is full, strong, and hard; in other instances, it is small, con- tracted, quick, and frequent. Severe headach is a very common at- tendant, and towards evening, and at night, more or less delirium usually occurs. In a great majority of cases, the lochia are entirely suppressed; in some instances a slight lochial discharge continues throughout the disease, and occasionally, though extremely seldom, this evacuation is even profuse. In general, the secretion of milk is somewhat diminished, but it rarely becomes entirely suppressed, as in puerperal peritonitis. In some cases of hysteritis,indeed,the breasts remain full and turgid with milk, during the whole course of the disease. The bowels are generally inactive, and the urine is small in quantity, of a deep red colour, and usually passed with much dif- ficulty and pain. The course of hysteritis is generally rapid. If, after four or five days continuance, it do not tend to resolution, it will most probably terminate in suppuration or gangrene. By a vigorous antiphlogistic treatment, however, the violence of the inflammation may often be broken down in the course of the first twenty-four hours, and reso- lution speedily established. When the inflammation tends to this favourable termination, the pain, tenderness, and swelling of the uterus abate—the pulse becomes slower, soft, and open; the skin re- laxed and moist; the tongue clean and humid; and the headach and general uneasiness gradually disappear. The lochia, also, usually begin to flow more freely, and the urine becomes more copious and natural in its appearance. The occurrence of suppuration in the substance of the uterus, is always attended with great danger. If the abscess bursts into the cavity of the peritoneum, or makes its way between this membrane and the external surface of the womb, into the cellular texture of the lower part of the pelvis, the issue will almost inevitably be fatal. Sometimes the abscess opens into the uterus, and the matter is dis- charged by the vagina. When the pus is evacuated in this way, the probability of a favourable termination will be very considerable. I have seen an instance where the uterine abscess formed adhesions with the peritoneum in the groin, and, after three weeks, the tumour was opened externally, and exit given to the matter. This patient finally recovered her health. Raiman states, that the abscess has, in * Dr. Dewees observes, in his account of the symptoms of this affection, that " the stomach is rarely much affected in the early part of the disease—at least vomiting seldom takes place." This does not accord with my own experience. In all the cases of unequivocal hysteritis I have ever met with, nausea, with oc- casional retching, occurred during the early period of the malady. HYSTERITIS. 377 some instances, burst into the bladder,* and cases are related, in which the matter was evacuated through the rectum. The occurrence of suppuration may be suspected, when, after an obstinate course of the disease, for five or six days, the pains become less severe, with a feeling of weight in the affected part, at the same time that the pulse becomes more frequent, attended with occasional slight chills; irre- gular distribution of heat over the body—some parts being cool while others are hot; irregular, partial, and cool sweats; fetid, and more abundant lochia; prostration of the muscular power; dry and red tongue, and a livid flush on one or both cheeks. The termination in gangrene is not a frequent event in this affec- tion, unless the peritoneum be implicated in the inflammation. The supervention of gangrene will be readily perceived by the occur- rence of the usual symptoms of mortification. A rapid cessation of the pain; great muscular prostration; dimness of vision; a death-like countenance; a profuse, cold, and clammy sweat; ice-cold extremi- ties; and an extremely small, weak, and rapid pulse, announce the occurrence of gangrene, and the inevitable doom of the patient. The foregoing description applies to hysteritis in its simple or un- mixed form—that is, inflammation of the proper substance of the uterus, without implicating its peritoneal covering in the disease. In many instances, however, the inflammation spreads to the perito- neum,—an extension of the local affection frequently met with in the worst forms of what is usually called puerperal fever. Cases of this kind almost invariably prove fatal. The extension of the inflamma- tion from the substance of the uterus to the peritoneum, is attended with an increased frequency of the pulse, tumefaction, and great ten- derness of the lower part of the abdomen; entire suppression of the lochia, " or an excessive discharge of them;" (Dewees,) cessation of the secretion of milk; great prostration of the muscular powers; fre- quent muttering delirium; constant recumbence on the back, with the knees drawn up and raised, and the shoulders elevated, to take off the tension of the abdominal muscles; a dry, coated, and brown tongue; and, towards the end, usually, diarrhoea. Cases of this kind are always rapid in their progress, and unless the inflammation be speedily subdued by prompt and energetic measures, collapse of the vital energies generally supervenes in fortj'-eight hours, and often sooner, from the time the peritoneal inflammation commences. Treatment.—The most efficient antiphlogistic means must be promptly and energetically pursued in the treatment of this affec- tion. As soon as possible after the commencement of the inflam- mation, blood should be drawn from a vein to the extent of produc- ing a very decided impression on the circulation, or an approach to syncope. If after the first efficient bleeding, the pulse rises again, and the pain and tenderness of the parts are not materially abated, venesection should be repeated, and again to the extent of causing a * Handbuch der Speciellen Med. Pathologie, &c. B. i. p. 358. Vol. I.—48 378 HYSTERITIS. very manifest reduction of the momentum of the circulation. When the activity of the heart and arteries has been moderated by general bleeding, and the disease is not adequately subdued, leeches should be applied over the region of the pubes, and to the vulva and peri- naeum. Immediately after leeching, a large emollient poultice should be applied over the lower part of the abdomen and the external organs of generation; and this application should, from time to time, be repeated, until the violence of the local affection is in a great mea- sure subdued. Dr. Dewees objects to the use of fomentations to the abdomen, in this affection, and asserts that they have done mischief. I have no experience with any applications of this kind, in the pre- sent malady, except emollient poultices applied after efficient vene- section and leeching; and to me it has always appeared, that very evident advantage was obtained from this application. Purgatives are, in general, highly useful in hysteritis. Calomel, in doses of from eight to twelve grains, followed in the course of four hours by a full dose of Epsom or Glauber's salt, will answer this purpose very well. After the first active purgative, two or three evacuations should be procured daily by the exhibition of small doses of calomel and of the neutral purgative salts. Irritating purgative enemata, generally, aggravate the patient's sufferings, and should not be employed. I have, however, known unequivocal benefit derived from injecting into the rectum from time to time, warm emollient fluids,—such us warm water and milk—decoction of althea—infu- sion of flaxseed—or simply warm water. In a case which I attended about two years ago, the patient was much relieved by injections of this kind. They are particularly beneficial in the declension of the disease. Blisters are much recommended by some writers; but Dr. De- wees thinks their usefulness is very doubtful. From my own ex- perience, I am disposed to ascribe considerable value to vesication in this affection. When employed, after the momentum of the cir- culation has been moderated by general and local bleeding, I am well satisfied that blisters will often do much good in this complaint. If after leeching we apply an emollient poultice over the lower part of the abdomen and vulva, and blisters to. the upper and internal part of the thighs, much advantage will in general result. Some benefit may also be obtained from the usual antiphlogistic diaphoretic remedies. Nitre, antimony and calomel in combination, forms an excellent compound for this purpose. The muriate of am- monia, a sprescribed under the head of intermitting fever, is a fa- vourite remedy with many of the German physicians, and I am inclined to think that it is very worthy of attention in this respect. Opium, in full and frequent doses, and in union with calomel, is a valuable remedy in this affection. Dr. Dewees, however, " thinks that in this, as well as in all diseases of high inflammatory action, opium is decidedly hurtful." My own experience has led me to a very different opinion. The powers of this narcotic in inflammatory CHRONIC INFLAMMATION OP THE UTERUS. 379 affections are not as yet sufficiently appreciated. That opium is not hurtful, "in all diseases of high inflammatory action," but. often highly beneficial, is admitted by many of the ablest practitioners of the present day. When given in active doses, and repeated so as to keep the system constantly under its full influence, it often con- tributes in a powerful degree to the reduction of the local and ge- neral phlogistic actions. By lessening the general irritability and sensibility of the system, the different organs and structures become less susceptible of the stimulus of the local inflammation, and all the sympathetic actions consequently abate in their violence; and, in like manner, by diminishing the morbid sensibility, and pain of the affected part, the inflamed capillaries will be more disposed to resume their healthy functions. Opium does not, generally, in- crease the momentum of the circulation, in fevers depending on local inflammation. I have frequently known, in violent cases of acute rheumatism, a full dose of opium to render the pulse less fre- quent, and much softer than it was before its exhibition. As this article, however, has a strong tendency to cause cephalic congestion, and may do injury in this way, where the system is plethoric, or the action of the heart and arteries very vigorous, it will always be best to delay its exhibition, until blood has been efficiently abstract- ed. When this has been done, and the bowels well evacuated, from one to two grains of opium, with the same quantity of calomel, may be given every three or four hours with the happiest effect in the present disease. Sect. V.—Chronic Inflammation of the Uterus. Chronic inflammation of the uterus, appears to be a very common affection; and, though frequently productive of very distressing consequences, is often misunderstood and consequently mismanaged. This affection is frequently the result of difficult or instrumental labours; and Mr. Guilbert observes, that it often arises from exces- sive venereal indulgence; and from rheumatic and gouty irritation. He mentions also, translation of erysipelas as a frequent cause of the disease; and it supervenes occasionally, in consequence of the final cessation of the menses, at the critical period of life, and even as the result of temporary amenorrhoea. Chronic inflammation of the womb, sometimes occurs in a periodical manner, and this is most apt to be the case, when it arises from erysipelas. Mr. Guilbert says, that females who do not suckle their infants, are more liable to this variety of uterine disease, than those who perform this interest- ing maternal function. Chronic inflammation sometimes affects the whole body of the uterus; but much more frequently, it is seated in the neck or mouth of this organ. Out of a hundred cases, says the author just men- tioned, there will, probably, not be ten in which the inflammation is not almost exclusively seated in the neck and mouth of the womb. 380 CHRONIC INFLAMMATION OF THE UTERUS. Many females affected in this way, either mistake their complaint, or conceal it; or from the slightness of their sufferings neglect to resort to medical aid, until serious, and often irremediable structural disease is established. Some experience only a sense of heat, with slight soreness in the lower part of the pelvis; others complain of dull or lancinating pains in the region of the womb, with occasional intermissions and exacerbations. In some cases a sense of weight is felt, as if the uterus were prolapsed, attended with occasional pains in the upper part of the vagina. In all instances, more or less of a leucorrhceal discharge attends; and when, at times, the inflam- mation is aggravated, this discharge becomes white and opaque, or purulent. Those who are affected in this way are apt to experi- ence considerable pain at the superior part of the vagina, during the venereal embrace; and, in some instances, the tenderness of the os uteri is so great, that the venereal act always causes extreme suffering. On examining per vaginam, the mouth of the womb is found irre- gularly enlarged, one side or lip being usually much swollen, and very tender to the touch. So great is the sensibility of this part, that the patient experiences severe suffering from the slightest touch of the finger on making the examination. In general, the mouth of the uterus is diverted from its regular position in the vagina, and directed to one side, or sometimes to the posterior or anterior part of the pelvis. If the disease has been of long standing, the engorge- ment, or swelling of the neck of the womb, is so great, as to form a large tumour embraced by the vagina. More or less pain in the back and loins occurs in nearly all cases; and the stomach usually sympathizes with the uterus, so as to give rise to a train of very harassing dyspeptic and nervous symptoms. In some cases, the inflammation continues for years, without the occurrence of any serious structural disorder of the womb; but in the majority of cases, the neck of this organ gradually enlarges, and becomes indurated, or scirrhous, and finally, often terminates in can- cerous ulceration. Many cases, that are usually regarded as simple leucorrhoea, are connected with chronic inflammation of the os uteri; and it is hence especially important, when called to prescribe for morbid vaginal discharges of a leucorrhceal character, to ascertain, by examination, the state of the neck and mouth of the uterus. The existence of inflammation and tumefaction may be suspected, when with a puru- loid vaginal discharge, the patient complains of heat, weight, sore- ness, or pain in the upper part of the vagina. Treatment,—When the pulse is irritated, or quick, frequent, and somewhat tense, it will, in general, be proper to draw blood from a vein—and this measure is particularly proper when the patient is of a robust and plethoric habit. The diet should be unirritating and digestible, and where the diathesis is manifestly phlogistic, the nou- rishment should be of the lightest kind, until the general irritated CHRONIC INFLAMMATION OF THE UTERUS. 381 condition of the system is removed. When there is reason to be- lieve that the bowels are loaded with feculent matter, a few active purgatives ought to be administered in the beginning of the treat- ment; but after the intestines have been thus thoroughly evacuated, small doses of some of the neutral purgative salts should be given two or three times a week, so as to keep up a gentle and regular action of the bowels. Much benefit is sometimes derived from the application of leeches to the perinaeum, and about the anus and vulva, or even to the region of the pubis. Mr. Guilbert, in the work re- ferred to above, speaks in the most favourable terms of the efficacy of leeches applied to the os uteri.* He has invented a speculum uteri, by which, he says, the application of leeches to this part is very easily effected; and he has given the history of several cases, in which this practice was adopted with prompt and complete success. That local depletion, in this way, is likely to do much good, we can- not doubt. In private practice, however, it would be difficult to induce patients to submit to this treatment; and there are few prac- titioners, I apprehend, who would be willing even to propose this measure, unless the urgency of the case were extremely great. Cupping above the pubis, and blisters applied to the sacrum, or to the internal surface of the thighs, will sometimes contribute materially to the reduction of the uterine inflammation. Some advantage may also be obtained from warm emollient injections into the vagina, but all astringent and exciting applications of this kind ought to be care- fully avoided, with the exception, perhaps, of a very weak solution of sugar of lead.t Internally we may employ small doses of balsam copaiva, but its use must be delayed until the measures already mentioned have, in some degree, moderated the local and general irritation. I have, in a few instances, derived considerable benefit from the internal use of the muriate of ammonia, in twenty grain doses, three times daily. When this article is dissolved in water, with a considerable portion of the extract of liquorice, it will, in general, be readily taken by patients; but without the addition of the liquorice, it is so extremely offensive to the taste, that very few are willing to employ it. If, after the inflammation, or the pain, tenderness and swelling of the neck or orifice of the womb are removed, a leucorrhceal dis- charge continues, it must be treated according to the directions given under the head of leucorrhoea, in the second volume. * Considerations pratiques sur les Affections de l'uterus. Par J. N. Guil- bert, M. D. &c. Paris, 1826. X The hip-bath—general warm bathing. Mild mercurial course, avoiding ptyalism; a few grs. of blue pill with two grs. of camphor and one-tenth tart. antimonii. 382 PERICARDITIS. CHAPTER XIV. OF THE PHLEGMASIA OF THE SANGUIFEROUS SYSTEM. Pericarditis. Inflammation of the pericardium is no very uncommon affection, and from the very important functions assigned to the parts imme- diately implicated, must be regarded as one of the most alarming and dangerous of phlegmasial diseases. The symptoms which usually attend the acute form of the dis- ease, are—sudden severe lancinating pains in the centre or cardiac region of the chest, extending occasionally to the epigastrium, or to the back between the shoulders, attended with more or less oppres- sive dyspnoea, palpitation of the heart, and a sense of weight and con- striction under the sternum and left side of the thorax. In most instances the patient is entirely incapable of lying down, more espe- cially on the left side. He is constrained to remain, almost immove- ably, in the sitting posture, leaning the body slightly forwards, and resting his head on the back of a chair or some other sufficiently ele- vated support. The slightest variation from this posture, unless very cautiously effected, is apt, in some cases of this kind, to give rise to sudden and most poignant pains in the region of the heart. Extreme praecordial anxiety, with a dry and short cough, usually attend; and in many instances, partial syncope or sudden feelings of great faint- ness occur, at intervals, during the progress of the disease. Along with these symptoms we have also strong evidence of cardial distur- bance in the state of the pulse. In most instances, the pulse is re- markably irregular, intermitting, frequently feeble, and sometimes so small as to be almost imperceptible. A few cases, indeed, have been recorded, in which the pulse remained in nearly a natural state. Tacheron relates an instance of this kind.* The face is gene- rally pale, with an occasional circumscribed flush on one cheek; the prolabia become more or less livid as the disease advances, and a slight puffy swelling is apt to occur about the eyes and temples. The hands and feet usually become slightly oedematous in the latter stage of the disease; and great general weakness almost always en- sues soon after the full development of the inflammation. The speech is commonly faltering, and in some cases the patient is unable to spit out, without giving rise to sudden and extremely severe darting pains in the region of the inflamed organ. Sometimes considerable headach attends, and occasionally much uneasiness and pain is expe- * Recherches Anatomico-pathologiques,&c. &c. PERICARDITIS. 383 rienced in the stomach, accompanied with tenderness to pressure in the epigastrium. It must not be supposed, however, that pericardial inflammation is invariably attended with the train of symptoms just described. There are few phlegmasial affections so liable to such remarkable variations in the attending symptoms, as the disease under considera- tion. In some cases very little or no pain is experienced in the region of the heart; and the disturbance of the heart's action varies greatly in different cases, or at different stages of the same case. Most commonly the heart palpitates tumultuously, and knocks vio- lently against the ribs; but in some cases, its action is so feeble that its pulsations are scarcely to be felt or heard. Although the majo- rity of patients are obliged to remain in a sitting or semi-recumbent posture, yet some are forced to lie immoveably on their backs, or on the right or left side. " But the strangest anomaly is, that the same patient who at one period of his disease has fixed himself immove- ably on the left side, will, at another, be forced to turn over and fix himself as immoveably on the right side." (Latham.) Pericarditis is not unfrequently complicated with inflammation of the neighbouring structures, as the pleura, lungs, mediastinum, dia- phragm, or stomach; and. in some cases the substance of the heart itself participates in the pericardial inflammation. In instances of this kind, the symptoms are, of course, correspondingly complex. Diagnosis.—From the complications just mentioned, the diag- nosis of pericarditis is often attended with much difficulty; and Laen- nec cautions, in all instances, against "too implicit a confidence" in the symptoms mentioned above as manifestations of pericardial in- flammation. Pericarditis, he says, may exist without any of these signs; and on the other hand, all of them may be present, without the slightest inflammation of the pericardium. M. Louis, however, asserts, that from a careful observation of thirty-two cases of this affection, he has been led to believe that the diagnosis is by no means so difficult and uncertain as is supposed by Laennec and others. This, he says, may be asserted, at least, of those cases that are free from complications. Where we find severe lancinating pains in the region of the heart, extending at intervals to the back and epigastrium, attended with palpitation of the heart; great irre- gularity, intermission, and smallness of the pulse; difficult respira- tion; occasional syncope or great faintness; inability to rest in the recumbent position, with more or less oedema of the extremities, we may infer, without much risk of erring, the existence of pericar- dial inflammation. If with these symptoms we find the cardiac region yielding an obscure or dull sound on percussion, while the other parts of the chest are resonant, the correctness of the diagno- sis will hardly admit of a justifiable doubt. But, although we may, with but little risk of mistake, infer the existence of pericarditis when the foregoing symptoms are present, it is well ascertained that rapid and violent pericardial inflammation sometimes occurs, and 384 PERICARDITIS. proceeds to a fatal termination, without at any period of its course manifesting a single symptom indicative of cardial disease. It is a very remarkable fact also, that cases of this kind occasionally simu- late inflammation of the brain so closely, that no one could for a moment hesitate to regard the disease as an instance of strongly marked encephalic inflammation. Dr. Latham has recorded several highly interesting cases of this kind. "One of the children at Christ's Hospital, had in the opinion of all who saw him the seve- rest inflammation of the brain. The attack was sudden, with great heat of the skin and frequency of the pulse. He had delirium and convulsions, and pointed to the head as the seat of his pain." On dissection, not the slightest trace of inflammation within the head was discovered, but the heart and pericardium were intensely in- flamed. M. Andral also relates a case where delirium, general con- vulsions, twitching of the tendons, and finally tetanic spasms, fol- lowed by paralysis of the upper extremities and fatal coma, occurred without the least sign of any particular affection of the head. On dis- section, the brain, spinal marrow, and their membranes, did not pre- sent the slightest traces of disease. But the pericardium exhibited strong marks of inflammation; its surface was covered with a layer of concreted lymph, and several ounces of a green and flaky serum was effused into its cavity.* Causes.—In general, whatever is capable of causing inflammation of any of the thoracic organs or structures, may give rise to pericar- ditis. Cold; mechanical injuries; the sudden healing up of old ulcers; the suppression of habitual evacuations; repelled cutaneous affections; the influence of the depressing mental emotions; and over exertion of the mind; may produce the disease. Metastasis of rheumatism and gout, is, however, by far the most common cause of this affection. Rheumatic irritation especially, is frequently con- cerned in the production of cardiac affections. Under the head of hypertrophy, its tendency in this way will be particularly noticed. Pleuritis and pneumonia sometimes involve the pericardium. Autopsicphenomena.—In most instances a considerable quantity of serum is found in the pericardium. Louis mentions cases in which more than a pint and a half of reddish or yellowish serum was collected; and Corvisart saw an instance where it amounted to four pounds. The internal surface of the pericardium is generally much injected, and often rough and uneven, or covered with more or less extensive patches of false membrane. In some cases a simi- lar pseudo-membranous formation covers the surface of the heart. M. Louis mentions one where false membrane, nearly half an inch thick in some places, covered the heart, so as to give it the appear- ance of the rind of a pine apple. Laennec asserts that the quantity * Pathological Essays on some of the Diseases of the Heart. By P. M. Latham, M. D. Physician to St. Bartholomew's Hospital. Lond. Med. Gazette, 1829. PERICARDITIS. 385 of serum effused into the pericardium, though considerable in the early stage of the disease, always decreases progressively, by absorp- tion, as the violence of the inflammation declines. In cases of great violence, there is generally very little or no serum effused; but in- stead of this, a large portion of firmly concreted albumen usually covers the heart and internal surface of the pericardium, and in some instances, fills the whole cavity of this membrane, uniting it more or less firmly with the surface of the heart* In cases that terminate favourably, this albumenoid concrete matter gradually becomes con- verted into cellular substance, "or rather into laminae of the same nature as the serous membranes." In some cases the pericardium is found very firmly adherent to the heart throughout its whole extent, by means of laminae of cellular structure thus formed. Cases are mentioned by some of the older writers, where the peri- cardium was supposed to be altogether wanting; but these were no doubt instances of firm adhesion of this membrane to the heart. Columbus relates the case of a student at Rome, who after having for a long time suffered frequent attacks of syncope, died suddenly. On dissection, the heart, he says, was found unprotected with a peri- cardium, t The pericardium has also been found affected with true scirrhous induration; and Dr. Friend asserts that he has found it above half an inch in thickness throughout its whole extent. J Chronic Pericarditis.—The chronic form of pericardial inflam- mation appears to be much more frequent than the acute. It is attended, in most instances, with mor&or less fixed pain in the region of the heart, subject to occasional exacerbations, particularly from even slight perturbating causes. Some degree of dyspnoea and pec- toral oppression is seldom wholly absent; and a short dry cough is apt to occur. The pulse, as in the acute form of the complaint, is small, and at times irregular and intermitting; and the heart is apt to be thrown into violent paroxysms of palpitation by slight corporeal exertions and mental excitement. Patients labouring under this affection, are generally timid, pusillanimous, and disturbed by ap- prehensions of evil, or of death. On percussion, the sound elicited over the region of the heart, is peculiarly dull; and when effusion has taken place, some degree of fluctuation may be felt by the patient. In most instances, oedema of the lower extremities occurs, and occa- sionally a puffy swelling appears suddenly in the face, particularly under the eyes, and after a day or two disappears again. When the sound on percussion over the cardial region is dull, and the extremities and face become puffy, we may conclude that considerable effusion of serum has taken place in the pericardium; and in this case the danger is always very great. Death from this affection often occurs very suddenly and unexpectedly; but in some * Laennec. t De Re Anatomica, lib. xv. p. 267—as quoted by Van Swieten. X History of Physick, p. 2. Vol. I —49 386 PERICARDITIS. instances a slow wasting of the body, and declension of the vital powers, under symptoms of general febrile irritation, gradually lead to a fatal termination. On dissection, the whole internal surface is, usually, found florid; but the pseudo-membranous exudation, so common and conspicuous in acute pericarditis, is but rarely met with in this form of the dis- ease. When albumenoid concretions of this kind do occur in chro- nic pericarditis, they are always " thin, soft, friable, and entirely resembling a layer of very thick pus." (Laennec.) The substance of the heart presents a whitish colour, " as if it had been macerated, several days, in water;" and it is sometimes of a much softer con- sistence than natural, whilst in other instances it possesses its normal degree of firmness. Laennec does not agree with those who suppose that the loss of colour in the muscular substance of the heart, is the consequence of inflammation; but he does not advance any facts which can be deemed sufficient to repudiate this opinion. Treatment.—A direct and active antiphlogistic treatment, is of course the only mode of management upon which any reasonable hopes of success can be placed. In cases attended with symptoms of pulmonic inflammation, the treatment should, in every respect, coincide with that which would be adopted in either pneumonia cr pleuritis. Where the pericardial inflammation has supervened sud- denly, soon after the disappearance of external rheumatic inflamma- tion, blood-letting cannot, in general, be carried to the extent which is proper in cases arising from^her causes. Indeed, the ordinary anti- phlogistic means usually employed in phlegmasial affections, will rarely subdue rheumatic pericarditis; and copious abstractions of blood, are not unfrequently productive of serious mischief. In cases of this kind, calomel and opium, given in full and frequent doses, in conjunction with moderate general and local depletion and proper revulsive applications, constitute the most valuable curative means we possess. Dr. Latham speaks in the most favourable terms of the employment of mercury in pericarditis. It is particularly valuable in rheumatic pericarditis, although much advantage may often be obtained from its use in every variety of the disease. " From acute pericarditis," says Dr. Latham, " which has proceeded to the depo- sition of lymph, nothing, I believe, can effect a perfect recovery, except mercury, given so as to excite moderate salivation." From my own observations, I am entirely convinced that calomel given to the extent of producing a general mercurial impression, is a valua- ble remedy in this affection. Where the disease is dependent on rheumatism, it will, I think, always be best to give the calomel in union with opium. In a case of rheumatic pericarditis, which came under my care about six months ago, I prescribed one grain of opium with three grains, of calomel, every four hours, with unequivocal benefit. About sixteen ounces of blood were abstracted with the lancet, and thirty leeches applied to the region of the heart, before the calomel and opium were resorted to. ACUTE RHEUMATISM. 387 Blistering on the back between the shoulders, whilst blood is abstracted by leeching or cupping from the anterior cardial region, is a very powerful auxiliary in reducing this affection. The saline hydro- gogue purgatives, are probably better suited to procure advantage in this affection than the other articles of this class of remedies. From what I have myself witnessed in relation to this point, I am led to believe that cremor tartar, with or without a portion of jalap, is the best pur- gative we can give in this affection. When the disease is of a chronic character, and there is reason to presume that serum has been effused in the pericardial cavity, diuretics will be proper. The squill in union with calomel, may be employed for this purpose. In this form of the disease, a more permanent counter-irritation over the region of the heart, than can be well obtained by blisters, should be kept up. Pustulation with the tartar emetic ointment, or a caustic issue, will in general answer this purpose well. CHAPTER XV. OF THE PHLEGMASIA OF THE FIBROUS AND MUSCULAR STRUCTURES. Sect. I.—Acute Rheumatism. Acute rheumatism generally commences with the ordinary initial symptoms of febrile affections from cold or atmospheric vicissitudes. A sense of chilliness, alternating with flushes of heat, with general lassitude, loss of appetite, and depression of spirits, are the usual symptoms which attend the development of the disease. In many instances, a general soreness and aching of the body accompany these symptoms. Sometimes the febrile reaction becomes completely established before the local rheumatic inflammation supervenes; in other instances, more or less pain is experienced in one or several joints, or in other fibrous structures, from the commencement of the attack; and occasionally, though rarely, the local affection occurs before any manifest general sympathetic irritation takes place. The parts affected with rheumatic inflammation are swollen, red, and ex- tremely painful—the slightest pressure or motion causing the utmost degree of suffering. When perfectly at rest, the patient often expe- riences some abatement of the gnawing and tearing pain during the day; but at night intense exacerbations usually take place. Whether the fever precede or rise with the development of the local inflam- mation, it always acquires additional violence as soon as the.local affection is fully established—the pulse becoming full, frequent, and vigorous; the skin hot and dry; the tongue coated with a white fur, changing to a brown colour, as the disease advances; the thirst very 388 ACUTE rheumatism. urgent; the bowels constipated, and the urine scanty, of a deep red colour, transparent, and without sediment. In very severe cases, headach, and, occasionally, slight delirium, attend during the exacer- bations. Bilious rheumatism.—Acute rheumatism is sometimes compli- cated with conspicuous derangement of the biliary organs. This is the rheumatismus acutus gastricus of Richter, and depends, according to Stoll, on gastric irritation from redundant and vitiated bile in the primae viae.* Like bilious pleurisy, it is the result of the united operation of cold and koino-miasmata on the system. This variety of the disease is met with in miasmatic districts during the cold and variable months of the year, more especially after a warm and sickly autumn. The disease is usually attended with con- siderable pain in the head; a yellowish or icterode hue of the eyes; a thick layer of brown fur on the tongue; occasional nausea and bilious vomiting. The quantity of bile thrown up is sometimes very great; and after each spell of vomiting, an immediate and often almost complete, though but temporary, abatement of the local rheu- matic pains usually occurs. Gonorrhozal rheumatism.—Rheumatic pain and swelling of the knees and ankles, is no uncommon consequence of gonorrhoeal irri- tation. In some instances, though rarely, the rheumatic affection becomes more general, very painful, and attended with very consi- derable febrile irritation. Cases of this kind have generally been ascribed to a suppression of the gonorrhoeal discharge. This is the opinion of Brodie, and of Swediaur; but Mr. Bacot thinks this ex- planation of its origin " is to be understood in a very qualified sense." It appears, however, to be pretty well ascertained, that " neither the affection of the joints nor the more general rheumatism, come on until the gonorrhoea is on the decline." Young persons of " stru- mous habits, florid complexions, and not particularly robust," a :e most liable to this form of rheumatic affection. This form of the disease is characterized by much puffiness and tenderness of the ankles, especially towards evening; the pain is not much increased by pressure—the stomach becomes deranged, and the appetite usu- ally fails altogether. Now and then, " all the symptoms are sud- denly relieved by an eruption of papulae in clusters; or sometimes by pustules in minute patches." This eruption may continue from a few days to several weeks. When it appears, both the pains and constitutional symptoms go off entirely.! The rheumatismus non febrilis recens of the German writers, though diverse from the chronic form of the disease, is not attended with very obvious symptoms of febrile reaction. It shows itself by more or less severe and sharp pain in some one of the muscular or aponeurotic parts of the body, particularly in the muscles of the * Ratio Meden. torn. ii. p. 25. f A Treatise on Syphilis, &e. by John Bacot, Esq. Surgeon, &c acute rheumatism. 389 breast, neck, and about the scapular region, and occasionally in the face and jaws. Sometimes the affected part is swollen and red; at others, neither swelling nor redness occurs. This variety of rheu- matic inflammation generally arises from the local application of cold, such as currents of air directed upon some particular part of the body.* Prognosis.—Although extremely painful, rheumatism is not a dangerous affection, so long as the inflammation remains in the exter- nal parts. When translated to some internal organ or structure— particularly to the heart, meninges of the brain, stomach, or lungs, the most serious consequences are to be apprehended. The duration of an attack of acute rheumatism is extremely va- rious, and depends much on the degree of constitutional predisposi- tion to the disease; and on the remediate management adopted for its removal. When the disease is about terminating, general diapho- resis, with a copious pale-red sediment in the urine occurs; and, in some instances, moderate diarrhoea accompanies the declension of the fever and inflammation. It never terminates in resolution with- out the concomitant occurrence of diaphoresis and a lateritious sedi- ment in the urine. It would appear from some observations of Dr. Chambers and Mr. Wigan, that the sweat in acute rheumatism is almost invariably of an acid quality, t I noticed this fact in a case I attended a few months ago. The patient wore a blue check shirt, the blue stripes of which were changed to a pale-red colour during the resolution of the disease. Rheumatism occurs but very rarely during early infancy. Scu- damore asserts, that infants are entirely exempt from it; but in this he is certainly wrong. I have met with several instances of acute articular inflammation, attended with the usual phenomena of rheu- matism, in children under two years old. Very aged persons also, are seldom affected with the acute form of rheumatism, although especially liable to the chronic variety of the disease. From the seventh to the forty-fifth year of age, is the period during which acute rheumatism is most apt to occur. Lean and muscular persons of a sanguineous temperament are, in general, much more liable to this affection than individuals of a fat and soft habit of body, or of a nervous or lymphatic temperament. Among the most common and powerful accidental predisposing causes of rheumatism are, derange- ment and irritation of the alimentary canal; the inordinate use of spirituous liquors; fatiguing exercise, accompanied with protracted and copious perspiration; and the habitual use of high-seasoned and heating articles of food; and the abuse of mercury. Cause.—Suppressed perspiration from cold or sudden atmosphe- ric vicissitudes is incomparably the most frequent exciting cause of rheumatism. It is on this account that the disease is so much more * Richter, Specielle Therapie, vol. ii. p. 36. X Medico-Chirurg. Rev. April, 1828, p. 176. 390 ACUTE RHEUMATISM. common during the damp, raw, and variable months of spring and autumn, than in the more mild and equable season of summer. In- deed, rheumatism is almost peculiarly a disease of cold and variable climates—its occurrence in the warm and more uniform latitudes being comparatively rare. Mercury is generally accused as a very frequent cause of rheumatism. It is doubtful, however, if it is ever, of itself, the exciting cause of this affection, although its very espe- cial tendency to predispose the system to the morbific influence of low and variable temperature is unquestionable; and it is, probably, by this effect alone, that the use of mercury is so apt to be followed by rheumatic affections. I have already adverted to gonorrhoeal irritation as an occasional cause of rheumatic affections. It would appear that the occurrence of the arthritic pains is in some way or other connected with the disappearance of the gonorrhoeal discharge; but whether the cessation of the discharge is to be regarded as the effect or the cause of the rheumatic affection, is as yet a matter of conjecture. In relation to the proximate cause of rheumatism, authors have expressed a variety x)f opinions. Formerly it was customary to regard the disease as depending directly on a peculiar morbific or rheumatic matter in the blood, which, being thrown or concentrated upon some particular part, was thought to be the immediate exciting cause of the local inflammation. Balfour advanced the opinion of its consisting in a peculiar inflammation of the cellular tissue; and Cullen supposed that an inflammatory state of the blood, in con- nexion with a peculiar phlogistic condition of the muscular struc- ture, constitutes the proximate cause of the disease. With Brous- sais, it, of course, is the consequence of the all-embracing gastro- enteric The opinion of Richter, that rheumatic inflammation is the consequence of irritation from retained perspirable matter (materia perspirabilis retenta,*) though savouring too much of humoral pathology for the prevailing taste of pathologists, is at least as plausible as any other doctrine that has been advanced on this subject, and by no means at variance with the immediate effects of its acknowledged almost invariable exciting cause. Whatever ideas may be entertained in relation to the proximate cause of rheumatic inflammation, it is now generally admitted that the seat of this inflammation is in the fibrous textures—more espe- cially in the aponeurotic and tendinous structures of the body. It is manifest, moreover, that this inflammation differs very materially from the other varieties of inflammation; and the opinion of Scuda- more, that it is, sui generis, of a strictly specific character, is sup- ported by its peculiar character and phenomena. The frequent and often rapid passage of the local affection from one part of the body to another, would seem to indicate something radically distinct, if not in the inflammatory action itself, at least in its immediate or * Specielle Therapie, vol. ii. p. 18. ACUTE RHEUMATISM. 391 proximate cause. This circumstance, too, favours the opinion that the disease consists in a peculiar diathesis, or general morbid con- dition of the system—the local inflammation being merely one of its effects, or external manifestations. We notice this migratory character in all inflammations which depend on some internal or constitutional affection. It occurs most conspicuously in gout, and in some varieties of erysipelas. Metastasis of rheumatic inflammation to internal organs or struc- tures, and consequent alarming and sometimes fatal consequences, is by no means unfrequent. It may pass upon the heart, diaphragm, stomach, bowels, intercostal muscles, and, in short, upon almost every sensible part of the body. When it is translated, to the heart, the patient is seized with acute pain and a feeling of great anxiety in the cardiac region, with palpitation, fits of partial syncope, and a pale, contracted, and distressed aspect of the countenance. Metastasis to the meninges of the brain, is attended with a sense of weight, and sometimes acute pain in the head, intolerance of light and sound, a wild and anxious expression of the countenance, occasional delirium, strabismus, and impaired vision.* When the stomach becomes the seat of the disease, violent cardialgia, nausea, vomiting, indigestion, " and symptoms imitating cancer or scirrhus of the pylorus" usually supervene. Cazenave says, that in some cases, nothing but a feeling of coldness or pain occurs in the epigastric region.t The. same writer states, that he has known the bladder to be affected with rheumatism—producing retention of urine, and much pain in the vesicle region. Sometimes the lungs become the seat of the disease, in which case symptoms of peripneumony supervene. When it attacks the intercostal muscles, or the pleura, the phenomena of pleuritis occur. Cazenave states, that he has repeatedly known rheumatic inflammation to fix upon the uterus and its appendices, giving rise to severe pain in this organ. I have lately seen an instance of sudden translation of rheumatic inflammation from the wrist to the bowels, in a young lady, which was speedily followed by symptoms of subacute peritonitis. On the fourth day the pain and swelling reappeared in the arm, and the abdominal affection speedily subsided. Dr. Johnson observes, in relation to this disease, that though not often fatal as external rheumatism, yet in its con- sequences, he is led, from " long and attentive observation," to regard it as being productive of " a very considerable proportion of those active enlargements or hypertrophiae of the heart, which we now so frequently meet in practice." Dr. Cox also refers to the " numerous cases of organic disease of the heart and pericardium, which he met with during his connexion with St. Guy's Hospital, * Observations on Acute Rheumatism and its Metastasis to the heart. By Thos. Cox, M. D. London, 1824. t Memoir on the Treatment of Rheumatism. By Dr. Cazenave. 392 ACUTE RHEUMATISM. that were referable to, or connected with rheumatitis."* His ob- servations have led him to believe that "the majority of cases of organic disease of the heart in young people, are connected with rheumatism." Diagnosis.—By the ancients, rheumatism and gout were gene- rally described under the common name of arthritis, and it does not appear that they regarded these affections as being diverse from each other. The essential identity of these two diseases has, in- deed, found advocates among modern pathologists, although the ge- neral sentiment, at present, is that they are radically distinct from each other. The principal distinguishing circumstances between these two affections are:—1. The periodical recurrence of gout after it has once invaded the system; whereas, rheumatism does not pos- sess this tendency, the patient often remaining entirely free from the disease during the rest of life, after having suffered an attack of it. 2. The distinct character of their causes; thus, rheumatism is conspicuously, and almost invariably, the result of atmospheric in- clemency or vicissitudes causing sudden suppression of the cutane- ous exhalation.t It is not produced, like gout, by indolence, in conjunction with the free use of vinous drinks, and rich, high sea- soned, and stimulating articles of diet. An attack of acute rheuma- tism is not usually preceded by uneasy sensations in the stomach, and other gastric disturbances. Gout is very often preceded by dyspeptic symptoms. 3. The predisposition to gout is often trans- mitted from parent to offspring. This is rarely, if ever the case, in relation to acute rheumatism. 4. Gout is most apt to occur in de- bilitated and relaxed habits; its occurrence in lean, muscular, and temperate persons inured to hardships and toil, being extremely un- common; whilst the reverse, in all these respects, obtains in rheu- matism. Treatment.—Although of a strongly marked phlogistic charac- ter, rheumatism is not so much under the control of direct depletion as most of the other phlegmasial affections. Blood-letting is un- doubtedly a very important auxiliary in the treatment of this dis- ease; but it is incapable, by itself, of subduing the local inflamma- tion, however copiously practised. Indeed, the very profuse, san- guineous evacuations so frequently resorted to in this complaint, so far from proving beneficial, lead often to very disastrous conse- quences; for experience has fully established the fact, that metasta- sis of the local affection to an internal organ is particularly favoured by thus draining the system of its blood, and impairing the vital * Loc. citat. preface, viii. X Richter says, rheumatism is always produced by external exciting causes, such as cold, and, therefore, more immediately from a materia perspirabilia reten- ta. Whereas, gout arises from internal causes, giving rise to a peculiar atony and weakness of thesy9tem. ACUTE RHEUMATISM. 393 energies. " We have long been convinced," says Dr. Johnson, "from attentive observation, that the system of detracting large quantities of blood, in cases of acute rheumatism, is productive of more frequent metastasis from the extremities to internal or- gans than a more moderate treatment. If we do quell the external inflammation, a retrocession to some weakened organ is too apt to take place. Of this we have seen several instances."* The records of medicine furnish us with many examples illustrative of the correctness of this-observation. The case reported by Dr. Kemper is a striking instance of this kind. This was a strongly marked case of inflammatory rheumatism; the fever was violent, and " the joints of her limbs, from the elbows and knees downwards, were affected with swelling, redness, and most acute pain." In five clays, nearly eleven pints of blood were abstracted from the patient. Metastasis of the disease soon took place, first to the lungs, and then to the head. At last the rheumatic inflammation returned to the extremities and relieved the internal organs.! Dr. Armstrong also, has related a case of this kind.J The inordinate use of the lancet, by debilitating the constitution, is, moreover, apt to prolong the dis- ease in a subacute or chronic' state, and to strengthen the predispo- sition to a recurrence of the affection. " In no way," says Scuda- more, " is a degeneracy into chronic symptoms so certainly induced, as by that injudicious employment of general bleeding which enfee- bles the constitution, and still leaves the rheumatic disposition in great force. Nor does the articular disease itself yield to the use of general bleeding in the manner which we might expect.§ Blood-letting is, however, not to be entirely neglected in this affection. It is only against the too common abuse of this evacua- tion that these observations are directed. In strong, muscular, and plethoric subjects, general bleeding, until some impression is made on the pulse, is a useful preliminary to the employment of the more efficient remedies in this affection. In general, one or two pretty copious evacuations in the commencement of the disease, will be sufficient to procure all the advantages this measure can afford. The attempt to render the pulse soft and moderate in its action by blood-letting in this disease, will almost always fail, unless blood be drawn to a very dangerous extent. The usual indication fur- nished by the buffy coat of the blood, for further depletion in in- flammatory affections, is wholly fallacious in rheumatism; for the buffy coat will generally continue in despite of the most copious and repeated abstractions of blood. " A surer practical indication may be taken from the form of the coagulum and its firmness. When it is exceedingly cupped, and when the inferior part beneath the stratum * Medico-Chirurg. Review, June, 1823, p. 215. | Philadelphia Jour. Med. and Phys. Sciences, No. 12. X Lond. Med. and Phys. Jour. No. 289. § A Treatise on the Nature and Cure of Rheumatism. London, 1827, p. 70. Vol. I.—50 394 ACUTE RHEUMATISM. of fibrine is very firm, it is a presumptive evidence that the heart and arteries are labouring under that morbid contractility which dis- tinguishes the inflammatory diathesis."* When the disease fixes itself early on some internal organ—par- ticularly the heart, diaphragm, or brain, it will be necessary to re- sort to prompt and decisive bleeding; but even in cases of this kind, it will be much better after one or two copious abstractions of blood, to resort to the use of opium and calomel, than to a repetition of the bleeding. Purgatives are always useful in this affection. I have often known the inflammatory condition of the system more effectually reduced by the operation of two or three saline purgatives, than could be effected by several copious abstractions of blood. The more drastic articles of this kind ought to be avoided. These are in some de- gree incompatible with that regular action of the cutaneous exha- lents which seems to be indispensable to the removal of this affection. Laxatives, on the contrary, are of much service by removing the sources of intestinal irritation—equalizing the circulation and mode- rating the febrile reaction, without causing injurious irritation by their direct impressions on the mucous membrane of the bowels. As a general rule, the saline purgatives are to be preferred. 1 have usually directed from six to eight grains of calomel at night, to be followed next morning by a small dose of Epsom or Glauber salts. Scudamore speaks very favourably of an aperient draught composed of small doses of carbonate of magnesia, carbonate of pot- ash, sulphate of magnesia, with tartarized antimony y acetum colchici, and lemon juice sufficient to neutralize the carbonate of potash, and a portion of water and syrup. Two ounces of Epsom salts, with a grain of tartar emetic, dissolved in eight ounces of water, and taken in doses of a table-spoonful every hour, is an excellent aperient in this complaint. Emetics have been much recommended in the treatment of rheu- matism, and my own experience has furnished me with some strik- ing examples of their usefulness. Horn asserts that he has derived more prompt advantage from emetics in this complaint, than from any other remedy.t I attended a gentleman, a few years ago, who was suffering extremely from an attack of acute rheumatism. The principal pain and swelling was in all the joints of the left arm, and in the right knee. He had been freely bled and purged before I saw him, but the pains continued unabated. With a view to excite dia- phoresis, and to moderate the febrile reaction, I prescribed a solution of tart, antim. Contrary to my intentions, the first dose produced pretty free vomiting. Almost immediately his pains were greatly mitigated, and continued so for three or four hours, and then gradu- * Scudamore, loc. citat. p. 70. f Uber d. heils. wirk. d. brechmittel in hitzigen rheumat. Archiv. b. viii. ■.2. ACUTE RHEUMATISM. 395 ally returned, though not to their former state of violence. On the following morning, I gave him an antimonial emetic, which pro- duced full emesis, and again the rheumatic pains subsided, almost en- tirely, for a few hours; they returned, however, as before, but so greatly diminished, that he was enabled to obtain considerable sleep during the following afternoon and night. On the third day, he took another emetic, after which the disease disappeared rapidly and completely, under the use of a few full doses of opium. I have, since that time, derived signal advantage from emetics in several cases of this affection. When rheumatism is complicated with functional disorder of the liver, emetics are particularly useful. In instances of this kind, the local pain will often almost entirely disappear for a time; and if full doses of calomel and opium are administered soon after the vomit- ing has ceased, convalescence will sometimes speedily ensue. Diaphoretics may be employed with advantage, although little or no benefit is usually derived from profuse sweating excited by remedies of this kind. A gentle and uniform diaphoresis is always serviceable. For this purpose, small doses of tart, antim. in union with calomel and opium;* or with camphor and nitrate of potash;t or Dover's powder with calomel, may be advantageously employed. Scudamore recommends the following diaphoretic and anodyne mixture as particularly beneficial in this respect: R.—Potassse carbonat. gr. cviii. Succi citric, (recentis)^ii. Misturae camph. jfiiiss. Liquoris opii sedativ. sjiss. ad jii. Syrup, tolutan. §ss. Antim. tartarisat. gr. i. ad gr. ii.—M. Of this mixture, one, two, or three table-spoonfuls are to be taken every hour or two, until the pain is re- lieved. The diaphoretic tendency of these remedies should be promoted by the use of warm diluents; such as a weak infusion of eupatorium perfoliatum, of elder blossoms, &c. Opium, under judicious management, is a valuable remedy in acute rheumatism. When employed in full doses, after proper venesection and purging, in combination with calomel, or with ipe- * R.—Tart, antimon. gr. i. Pulv. gum. opii. gr. iii. Calomel gr. iv. Pulv. sacch. albi gr. xii—M. Divide into eight equal parts. S. Take one every two hours. X R.—Tart, antimon. gr. i. P. g. camph. gr. viii. Calomel gr. iv—M. Divide into eight equal parts. S. Take one every two or three hours. 396 ACUTE RHEUMATISM. cacuanha, or tart, antim.* it seldom fails to procure speedy relief, and to hasten the resolution of the local and general inflammatory action. When, after copious depletion, or from constitutional fee- bleness, the rheumatic inflammation passes upon some internal or- gan, opium is almost the only remedy upon which any reasonable hope of advantage can be placed. In my own practice, I have had many striking examples of the usefulness of this narcotic in the pre- sent affection. It should be given in full doses, and repeated every three or four hours, until relief from the pains is procured. Small doses of opium have a tendency to increase the phlogistic diathesis, whilst large ones, properly repeated, generally produce a contrary effect in acute symptomatic fevers. " It is worthy of consideration," says Scudamore, " that so powerfully does pain modify the influ- ence of opium on the nervous system in every kind of disease, that it may be given in the boldest doses without hazard or ill effect, when pain is intense; and in no way except by the active repeti- tion of such doses can it be really efficacious when the occasions for it are urgent." Dr. Cazenave very justly observes, that the timidity with which this narcotic is usually administered in acute rheuma- tism, is the cause of its frequent failure in doing conspicuous good. His mode of using the opium, in this affection, is to give a grain of it every hour, " till a complete calm is established, or an abundant perspiration induced." Most practitioners who are in the habit of employing opium in rheumatism, use it in combination with calomel; and this has ap- peared to me the best mode of using it. After venesection, and the free operation of a cathartic,! generally resort at once to opium and- calomel, in the proportion of one grain of the former to two of the latter every three or four hours, until the gums are slightly affected; after wdiich I continue with half a grain of the opium, at first every three hours, and gradually prolonging the intervals in proportion as the disease subsides. I have frequently found, that as soon as the mercurial action was established, the skin became moist and re- laxed, the pulse soft and less frequent, the urine sedimentous, with a rapid declension of the local and general affections. Dr. Arm- * Tartarized antimony and opium have been employed with signal efficacy in rheumatism. Dr. Findlay, of Circleville, Ohio, has published an account of several severe cases of this disease which yielded very promptly to a combina- tion of these remedies. He gave about one grain of the antimony with two- thirds of a grain of opium every hour.(a) I have myself lately employed this remedy in several cases, and with very speedy and entire success. Not more than four doses were required in an extremely severe case of lumbago, to put an entire stop to the pain. M. Lallemand speaks very favourably of grain doses of tart, antimony in rheumatic affections; and it is, in fact, a remedy of excellent powers in this respect. (a) North American Med. and Surg. Jour. vol. x. p. 167. ACUTE RHEUMATISM. 397 strong observes, that after prompt venesection, followed up by purga- tives with calomel and opium, recovery is often surprisingly rapid. Many highly respectable authorities might be cited in favour of" the united employment of these two articles in rheumatism.* "This treatment of acute, and we may say chronic rheumatism," observes Dr. Johnson, " is employed by many practitioners, and it is that which we have had recourse to for twenty years past."t It is not necessary to continue the calomel to the extent of producing free ptyalism. The slightest evidence of the mercurial action in the gums, is in general sufficient. The cinchona was formerly much recommended in the treatment of this affection. When, after depletion and purging, distinct re- missions of the febrile symptoms occur, particularly in weak and relaxed habits, the powdered bark or quinine may be employed with advantage. But in robust, muscular, and sanguineous habits, it is much more apt to do harm under any mode of management, than benefit. I have known very manifest injury done by the bark in this affection. During convalescence it is a proper and useful re- medy. Colchicum was at first prescribed only in the subacute or chronic forms of rheumatism; but later experience has shown that it maybe employed with equal benefit in the acute form of the disease. Mr. Hayden, in his work on the remedial powers of this root, asserts, that it possesses very considerable powers in controlling the action of the heart, and subduing inflammatory excitement. I have exhibited this article in seven or eight cases of acute rheumatism. In one instance it removed the disease completely in the course of three days, although previously very violent, and after calomel and opium, tart. antimon., venesection, and free purgation, had been ineffectually used. In a few instances it appeared to do some good, but in others no advantage whatever resulted from its use. Recently, however, I prescribed it in two instances of a subacute character with the hap- piest effect. Both patients were relieved by it in forty-eight hours, although the disease had for several weeks resisted other modes of treatment. Scudamore recommends the following formula for ad- * Dr. Chambers, of St. George's Hospital, London, gives ten grains of calo- mel, with two of opium, every night, or night and morning, with a daily dose of black draught to evacuate the bowels. He states, that as soon as the mouth be- comes affected, the symptoms usually subside. He does not push the medicine to the extent of producing ptyalism.—Med. Chir. Rev. vol. v. p. 566. Mr. Gosse, of Geneva, has employed calomel and opium to ptyalism with success, in acute rheumatism. From some chemical experiments which he made with the blood of persons under salivation, he found that it contained much less albumen, as well as cruor, and was more liquid than usual; and that it is there- fore less inflammatory. Similar opinions have been expressed by Dr. Farr and Mr. Travers.—Med. Chir. Rev. vol. i. p. 482. f Med. Chir. Rev. October, 1826, p. 566. 398 CHRONIC RHEUMATISM. ministering this remedy, where the inflammatory diathesis is not strong: R.—Liquor, ammon. acetat. §ss. Vini colchici gtt. xx. ad xxx. Syrupi papaveris ^i. Misturae camph. %i.—M. This draught is to be taken every sixth or eighth hour. The vinous tincture of the colchicum seed may be given to the extent of from 20 or 30 drops, with about a scruple of calcined mag- nesia every four hours, until slight nausea or purging is produced. When acute rheumatism continues until it assumes a subacute cha- racter—the pulse remaining irritated, small, sharp, and frequent, and the countenance pale, while the affected joints are swollen, painful, and oedematous—great benefit may sometimes be derived from the extract of stramonium, given in quarter grain doses every four hours until vertigo ensues. I have succeeded in removing the disease, in a short time, in several instances of this kind, by means of the stra- monium, after various other modes of treatment had been employed without avail. Very little advantage is in general to be obtained from local treat- ment during the active period of the disease. After the general inflammatory excitement has in a great degree subsided, benefit may be derived from leeching the affected parts. I have also known much good done by blistering the inflamed joints under such cir- cumstances. The treatment by compression, so strongly recommended by Balfour, has not met with much approbation; less I think than it deserves. I have in a few cases of subacute rheumatic inflammation, known very considerable relief obtained from a flannel roller applied pretty firmly round the affected joint.* The diet should, of course, consist of the mildest liquid farina- ceous articles of food. The drink may be cool and acidulated, except when diaphoretics are administered, when tepid diluents should be used. The temperature of the sick chamber should be kept comfortable and uniform. Sect. II.—Chronic Rheumatism. The symptoms of chronic rheumatism are much less uniform and definite than those which characterize the acute form of the disease. Chronic is often the consequence of acute rheumatism; but it occurs also, frequently, as a direct consequence of exposure to cold and damp air, more especially when the system is under the influence of mercury. The affected parts are commonly neither swollen nor red; * Observations on the Pathology and Cure of Rheumatism. By William Bal- four, M. D.—Edinburgh Med. and Surg. Journal, April, 1825. CHRONIC RHEUMATISM. 399 nor is there often any manifest fever connected with the chronic variety of the disease! although quickness, tension, and contracUon of the pulse are in some instances present in the evening, and during the night. The pain often wanders from one part to another, fixing itself, by turns, in the head, shoulders, knees, wrists, fingers hips, loins, &c%-more especially in those cases which approach the subacute character. Some individuals are hardly ever entirely free from pain; others are affected with it only occasionally, on the occurrence of damp and cold weather. In some instances the pain is seated in the joints; in others, in the muscles and parts situated between the joints. After remaining at rest for a while, the patien feels stiffness and pain on attempting to move the affected limb; but on using exercise, until the body becomes warm, both the pain and stiffness are apt to disappear. Those who are subject to this form of the disease, generally feel a dull aching pain in one or more joints, on the approach of stormy and rainy weather. Severe and invete- rate cases of chronic rheumatism are apt to give rise to organic dis- ease of the tendons, bursae mucosae, with wasting and hardening ol the muscular structure about the affected parts. The ligaments also, sometimes become rigid, thickened, and the joints stiff. A jelly-like effusion into the cavity of the affected joints occurs occasionally. (Scudamore.) . . . When the disease affects the muscles of the loins, it is called lum- bago. Lumbago is distinguished from nephritis by the absence of pain along the ureters, of retraction of the testicles, of the frequent desire to void urine, and of the nausea and vomiting which charac- terize the renal disease. In lumbago too, great difficulty and pain is experienced in bending the body forwards on the hips. In nephri- tis no uneasiness is caused by this movement. When the periosteum of the anterior aspect of the tibiae, or of the ulna, or os frontis, be- comes thickened and tender to the touch, we may presume that the chronic rheumatic affection is syphilitic, or mercurial. Chronic rheumatism sometimes occurs as the sequel of the acute form of the disease; and it arises frequently, also, as a direct conse- quence of suppressed perspiration from cold, damp, and variable weather. It is generally supposed that the action of mercury is particularly apt to give rise to chronic rheumatic pains; but it is extremely doubtful whether it possesses any direct tendency in this way. That the system, when under the mercurial influence, is ex- tremely susceptible of the injurious effects of cold and humid air, is indeed sufficiently ascertained; and it is probable that when rheuma- tism follows the constitutional operation of mercury, it is always the immediate consequence of subsequent influence of cold. Syphilis is apt to give rise to distressing chronic pains of a rheumatic charac- ter, but even where syphilis appears to be its cause, it is probably often the consequence of improper exposure while the system is under the mercurial influence. Mr. Teale has recently published a small work on subinflamma- 400 CHRONIC RHEUMATISM. tion and irritation of the spinal marrow, in which he asserts that not only neuralgic but rheumatic affections frequently depend on irrita- tion, or a slight degree of inflammation, at the origin of the spinal nerves. His observations on this subject appear to me highly im- portant, and from an instance which has quite lately come under my notice, I am satisfied that in some cases at least, chronic pains of a rheumatic character depend on spinal irritation. Dr. J. K. Mitchell, of this city, has, within a short time, published an interesting paper on this subject, in which he has detailed several striking instances of the speedy removal of severe pains of this kind, by cupping over the spinal region. It would appear from the observations of Teale and Mitchell, that in many cases of fixed pains, simulating rheuma- tism, one or more of the vertebrae of the spine are very tender to pressure, and that, if in such cases, leeches or cups be applied over the diseased portion of the spinal marrow, almost immediate removal of the rheumatic pains will be effected. In the case which occurred in my own practice, the patient had complained of constant severe pain in the left foot for several months, and the usual means for the cure of such affection, procured only slight temporary benefit. In- structed by the cases reported by Dr. Mitchell, I at last examined the track of the spine,and found two of the lower lumbar vertebrae mor- bidly sensible to pressure. I directed thirty leeches to the part, which afforded great relief, and in a few days afterwards more blood was drawn from the same spot by cupping, and this had the effect of en- tirely removing the disease in the foot. When the pains are situated in the head and upper extremities, the spinal affection, if any exist, will be found in the cervical vertebrae; and when a part about the chest, and upper portion of the abdomen, is the seat of the painful affection, there will probably be spinal irritation in one or more of the dorsal vertebrae. Under the head of neuralgia, I shall again have occasion to speak of this subject; and, in fact, the painful affections which result from this cause, are probably always strictly of a neu- ralgic character, although often mistaken for chronic rheumatic in- flammation. I must again repeat, that the facts developed by Mr. Teale, are highly interesting, and will, no doubt, receive due atten- tion from the profession. Treatment.—Unless the patient be robust, vigorous, and pletho- ric, general blood-letting is not only useless, but often injurious, in the strictly chronic form of the disease. Attention should be paid to the state of the digestive functions, and to the bowels. Where the appe- tite is weak and variable, and the bowels inactive, five or six grains of blue mass should occasionally be taken at night, followed in the morning with some gentle aperient.—such as the aromatic tincture of rhubarb; or a small dose of the compound infusion of senna. Where there is a general sluggishness orlanguor of the system, the cinchona bark, or quinine, will sometimes prove decidedly beneficial. Certain diaphoretics of the stimulating kind have been much employed in the treatment of this variety of rheumatism; and of these,gum guai- CHRONIC RHEUMATISM. 401 acum has held by far the highest rank. In individuals of a relaxed and phlegmatic habit of body, and in old persons of a worn-out con- stitution, it may be used occasionally with much advantage; but in persons of a contrary habit—plethoric, athletic, and phlogistic—it will seldom do good, and is even apt to do harm by its heating and irritating qualities. The usual mode of giving it in the form of a tincture, renders it still more objectionable in habits of this kind. In all instances, perhaps, it is best to give it in the form of an aqueous mixture, thus: R.—Pulv. g. guaiaci §i. -----g. arabic sjiii.—Triturate them together in a mortar, and add gra- dually ten ounces of cinnamon water. Of this, three or four table-spoonfuls may be taken daily. In cases partaking of a subacute character, or in such as result from the influence of cold while the system is under the operation of mercury, tart, antimon. will occasionally prove beneficial. In in- stances of this kind, I have used this article dissolved in a decoction of the root of burdock, (arctium lappa,) with excellent effects. A. grain of the tart, antim. should be dissolved in a pint of the decoc- tion (an ounce of the root to a pint of water) and drank in the course of the day. In such cases, however, more advantage may in ge- neral be derived from the judicious employment of mercury. In syphilitic and mercurial rheumatism, the production of a gentle mercurial impression on the system, with the concomitant employ- ment of the compound decoction of sarsaparilla, will often effectu- ally eradicate the disease. But even in cases which are not con- nected either with a syphilitic taint or with mercurial disease, this remedy will sometimes prove decidedly beneficial. In invete- rate and obstinate cases of chronic rheumatism, says Scudamore, " a well-conducted mercurial course, so as to produce and keep up a very moderate ptyalism, will sometimes prove successful after the failure of all other means." Advantage may be obtained from the use of the vapour-bath as an auxiliary to the mercurial course. I have used the following decoction, conjointly with mercury, with peculiar advantage: R.—Rad. sarsaparil. ^iii. Fol. cymapylla umbelat. ^iss. Rad. mezerion giii. Cort. ulmi fulv. §iss. Aqu. fervent, ifeiii.—To be boiled down to three half-pints; of which a wine-glassful is to be taken four times daily. In the same variety of chronic rheumatic pains, I have also admi- nistered the sulphate of zinc, in one grain doses three times daily, with the happiest effects. In one instance, after mercury, sarsapa- rilla, and a variety of other remedies had been fully tried without success, the zinc gave complete relief. Vol. I.—51 402 CHRONIC RHEUMATISM. The extract of stramonium is highly recommended as a remedy in this affection by Dr. Marcet; and it is unquestionably an article of very valuable powers, in chronic painful affections, unconnected with a phlogistic state of the system. Twenty years ago I em- ployed the tincture of the stramonium seed in chronic rheumatism; and I have frequently found it promptly and completely successful, although often also entirely disappointed in its use. In some parts of the United States it has long been used as a domestic remedy in this affection; and it was from having seen it successfully em- ployed by an old female in a case which had foiled all my ef- forts, that I first learned its remediate powers in this disease. I usually give 20 drops of the saturated tincture of the seed three times daily; and direct it to be continued until vertigo, or symp- toms of gastric disturbance ensue. I have also employed the ex- tract of stramonium in union with lactucarium, as is recommended by Scudamore, with excellent effect. " In some recent attacks," says this writer, " in which wandering nervous pains have been mixed with lumbago, the effects of this combination have been surprisingly successful. In a few cases, even of long standing, I have derived much satisfaction from this remedy." Colchicum is a remedy of considerable powers in chronic rheu- matic affections. I have found it most useful, however, in subacute cases, and in such as are the consequence of the acute form of the disease. In instances of a strictly chronic character, I have never derived any obvious advantage from this article; in such cases, it is, I think, inferior in efficacy to the stramonium. In mercurial and syphilitic pains, arsenic will often manifest very excellent powers. It may even be given with occasional advantage in old and obstinate cases arising from other causes—and it is said to be particularly beneficial in such as depend on the repul- sion of some chronic cutaneous affection. In several instances of a mercurial origin, I have prescribed Fowler's solution with complete success. After what has already been said above, I need scarcely dwell on the propriety of examining the spinal column, in chronic pains of a rheumatic character. When any portion of it is found unusually tender to pressure, leeches, cups, or a blister, should immediately be applied over the tender part. If the disease be the consequence of spinal irritation, it will frequently speedily disappear under the use of these local remedies. A great variety of other internal remedies have been recom- mended for the cure of this form of rheumatism. Of these, savin, nux vomica, phytolacca decandra, dulcamara, hyoscyamus, sul- phur, turpentine, and xanthoxylum fraxineum are the most im- portant. The savin is an old remedy in chronic articular pains;* I knew an empiric, about twenty years ago, who was noted for his * Rave, Beobachtungen, &c.—Munster, 1796. CHRONIC RHEUMATISM. 403 success in curing chronic rheumatism. His remedy was an electuary composed of savin, sulphur, and honey. I have prescribed it in a few instances with benefit; but in several cases its effects were mani- festly injurious. In chronic rheumatic pains of the hips (sciatica) and muscles of the loins (lumbago) the spirits of turpentine is among our most efficacious remedies. Home states, that he cured five out of seven cases of sciatica with this article.* Within the present year 1 suc- ceeded completely in removing a violent and protracted case of this affection by the turpentine, given in doses of twenty drops with a scruple of lac sulphuris three times daily. I have known the infu- sion of capsicum employed with marked advantage in a case of inveterate chronic rheumatism; and the juice of the poke-berries (phytolacca) is a familiar remedy in this affection, and has occasion- ally done considerable good. While practising in Lancaster county, I saw several instances of the successful use of a decoction of xan- thoxylum in chronic rheumatism. Professor Wendt has found an infusion of the clematis recta and vitaba a very useful remedy in this disease. Various external applications have been resorted to with advan- tage in this affection. The application of the tourniquet, so as to cause a temporary interruption in the circulation of the affected part, is said to have done much good.t Lately, the vapour of cam- phor has been used with success in chronic rheumatism by M. Delormel and M. Dupasquier.J The whole surface of the body, with the exception of the head, is to be exposed to the fumes of camphor, in an apparatus similar to the one used for the sulphurous vapour-bath. The camphor is evaporated by throwing it upon a dish of hot coals. Acupuncturation has, of late years, been practised by many physicians in local rheumatic pains unconnected with fever; and the numerous accounts that have been published respecting its effects, are sufficiently favourable to entitle it to considerable attention. Mr. Berlioz observes, that "vague and wandering rheumatism some- times attacks the external muscles subservient to respiration; the patient is obliged to remain motionless; every motion of the trunk compels him to cry out; deep inspiration is very difficult; and cough occasions such intense pains that expectoration is impossible. Acu- puncturation dissipates instantly this state of distress, and renders the muscles their full liberty of action. In the space of one or two minutes, a patient whose sufferings drew from him tears, becomes entirely relieved." This operation has been found particularly effi- cacious in lumbago; and instances of its successful employment in * Clinical Observations and Experiments. t Richter's SpecielleTherapie, b. ii. s. 61.—Abhandl.fur Pract. Arzte, b. xx. p. 509.—See also Duncan's Annals for 1801. X Rev. Medicale, Mai, 1829, p. 298. 404 GOUT. sciatica have been reported. Acupuncturation should, however, never be practised in cases attended with general febrile irritation; or, in inflammations approaching the acute character. Electro-puncturation—that is, inserting two needles, and con- necting them with the opposite poles of a weak galvanic pile, has succeeded in cases after ordinary acupuncturation repeatedly per- formed had entirely failed. Dr. Graffe has reported a very severe case of rheumatism, of several years standing, which after having resisted every remedy and mode of treatment, that could be sug- gested, yielded, at last, to the influence of electro-puncturation. (Graffe <§* Walt her's Journal.) Rubefacients are always useful in cases of a strictly local charac- ter. Camphor dissolved in aether, as recommended by Ferriar, is an excellent application for this purpose. I have generally preferred using the following liniment: R.—Spir. camphor. Aqua? ammon. aa ^iss. 01. olivar. %i. Spir. vini. rect. ^iv.—M. The warm bath, in conjunction with mercurial or diaphoretic re- medies, has been useful in this affection. Baths and douches of artificial sulphurous waters have been particularly recommended. In local rheumatic affections, advantage may sometimes be obtained from blistering or cupping the affected part; but the benefits derived from means of this kind are seldom more than temporary. Sweat- ing, induced by muscular action, particularly by walking, with an additional quantity of clothing, rarely fails to give temporary relief, and has been known to remove the disease altogether by frequent and regular repetition of the exercise.* Sect. III.—Gout. Gout is a constitutional affection, depending on a.peculiar diathe- sis, and manifesting itself in its regular form by external local inflam- mation of the fibrous structures and fever of the synochal grade. In relation to its symptoms and progress, however, it is subject to certain prominent modifications, which have given rise to its divi- sion into the three following varieties: acute, chronic, and retroce- dent gout. 1. Regular gout.—The acute or regular form of the disease occurs in paroxysms at longer or shorter intervals, leaving the patient in an apparently perfectly healthy condition during the inter- mediate periods. Occasionally the paroxysm comes on suddenly, without any warning of its approach; but, in by far the greater num- ber of instances, it is preceded by various premonitory symptoms: * Marcet, Lond. Medico-Chirurg. Transactions, 1812. GOUT. 405 such as disturbed digestive function; a peculiar, uneasy, anxious, and empty feeling in the pit of the stomach; a sense of tension and weight in the abdomen; an irritable state of the bladder; flatulency and acid eructations; costiveness; a white tongue; giddiness; great lassitude; yawning, and stretching of the legs; drowsiness, with dis- turbed sleep, depressed spirits, and debility. In some instances, a disagreeable itching of the skin occurs a few days previous to the attack; and in most cases, the urine acquires a deep-red colour. Some persons experience a feeling of numbness and formication in the lower extremities, with coldness of the feet and legs, before the paroxysm comes on. Sometimes the appetite is depraved and vora- cious, attended with occasional nausea and vomiting. Not unfre- quently blennorrhozal discharges occur from the bowels or bladder, or a copious secretion of mucus takes place in the bronchia. Some patients experience a sensation as if warm, or more commonly cool air were passing in a gentle stream, up and down the extremity, which is about becoming the seat of the disease. According to Van Swieten, the venereal propensity is sometimes particularly urgent just before the accession of the attack.* Of all these symptoms, the dyspeptic, or those indicative of gastric disturbance, are the most common precursors of the gouty attack. The duration of this pre- monitory period is very indefinite, and varies from a few hours to many days. The attack generally comes on at night. About two or three o'clock in the morning, the patient is roused from sleep by a severe pain in the ball of the great toe, or in the heel, or instep of one foot. Chills or rigours speedily ensue, terminating, after a short period, in febrile reaction. The pain now becomes more and more severe; the pa- tient is restless, his skin hot and dry, and the pulse frequent, full, and generally hard. About five o'clock in the morning, some remis- sion in the general and local symptoms usually occurs, with more or less profuse perspiration, and a short interval of imperfect rest is ob- tained. In some instances, the pain and fever continue with una- bated violence, until about the middle of the following night, when they gradually decline, under a moderate flow of sweat—the patient sinking into a quiet sleep towards morning. In very severe attacks, however, no obvious remission of the symptoms takes place, until the third or fourth morning. In all instances, however, the sufferings of the patient are greater during the fore-part of the night than in the day. When the affected part is examined in the morning after the accession of the paroxysm, it is found swollen, red, and the veins of the foot greatly distended with blood. The swelling is of an oedematous character, more especially after the disease has continued a few days. The tenderness of the inflamed joint is so great, that the weight of the lightest bedclothes is often insufferable, and every motion or agitation of the limb excites the most torturing pains. In * Comment, vol. xiii. p. 44. 406 GOUT. slight attacks, the constitutional symptoms are moderate; but, in the severer cases, the febrile excitement is always very considerable. The digestive functions are almost invariably conspicuously derang- ed; the tongue is furred, the appetite wholly depressed, the thirst urgent, the bowels constipated, with colic pains, and a sense of un- easy weight in the epigastrium. An unusual degree of nervous irri- tability prevails during the paroxysm, the patient being generally fretful, irritable, and difficult to please. The duration of a first paroxysm of the disease is seldom less than five, or more than nine days; but in subsequent attacks, it is often protracted beyond the second, or to the end of the third week. After the disease has subsided in one foot, it occasionally attacks the other, and passes regularly through its course, as in the first instance. The patient is usually left in a much better state of health, after the complete subsidence of the paroxysm, than he enjoyed previ- ously to the occurrence of the attack. His mind and body are, as it were, renovated; his appetite and digestion is good, and his powers, both mental and corporeal, more lively and energetic. Sooner or later, however, according to the degree of constitutional predisposi- tion, and the habit of living, the paroxysm is renewed. At first, the return of the disease is generally at long intervals; in some cases, only after a period of three or four years; though more commonly, its first visits are annual. The intervals of its recurrence gradually become shorter, in proportion as the constitutional energies are en- feebled by its attacks, until at last, "the patient is hardly ever tole- rably free from it, except perhaps for two or three months in the summer." (Cullen.) The periodicity of gout is occasionally very regular. Scudamore mentions an instance where the attack returned regularly on the 12th of April, for three years in succession. Such a strict periodical recurrence of the disease, is nevertheless very rare. At first, the inflammation occurs generally only in the feet; but when by the frequent recurrence of the attacks, the system is weak- ened, and the gouty diathesis strengthened, several joints sometimes become simultaneously affected, or the inflammation passes succes- sively from one external part to another, in the same paroxysm. (Scudamore.) " The external appearances of the disease," says Scu- damore, " vary considerably, according to the situation and particu- lar^ texture of the part which is affected. The redness of surface, together with the oedematous swellings, are most remarkable on the great toe, on the foot, the back of the hand, and at the elbow; while at the ankle, knee, and wrist, the increased bulk is produced chiefly by the distention of the bursas, and the sheaths of the tendons, and takes place often with little change in the natural colour of the skin." The sequelse of gout are various, and sometimes of a very distres-' sing character. The liver always suffers more or less functional disorder, and in some instances, undergoes structural derangement. The stomach seldom escapes becoming permanently debilitated from repeated attacks of the disease. The local effects of repeated attacks GOUT. 407 of gout are sometimes less distressing than the general affections which result from it. The tendons about the affected parts^become hard and knotty, and in some instances complete anchylosis ensues. Chronic gout.—When, from the repeated attacks of the acute form of the disease the system becomes enfeebled, or where there is an original deficiency of constitutional energy connected with the gouty diathesis, the disease does not manifest itself by paroxysms of acute inflammation, but by chronic, wandering, and irregular pains, bearing much resemblance to chronic rheumatism. The pain in chronic gout is usually but moderate during the day, the patient experiencing only a sense of alternate heat and coldness in the affected parts; at night, however, it is generally severe and aching. A feeling of numbness and weight is experienced in the diseased parts, and slight cramps are apt to occur during the fore- part of the night, and the sleep is restless, and interrupted by sud- den startings. The affected joints retain their natural colour, or present only a slight purplish hue; but they become oedematous, tender, and more or less stiff; and the neighbouring muscles are weakened, and sometimes diminished in size. The inflammation often passes successfully from one joint to another, or it leaves its original seat, and fixes upon some distant joint, and after having re- mained there for a while returns to the part it had left. There is rarely any very conspicuous fever; but the digestive and biliary organs are generally very prominently deranged. The dys- pepsia attending this form of the disease, says Scudamore, is par- ticularly characterized by great oppression, and flatulent distention of the stomach after a full meal, together with heartburn, and occa- sionally a sense of coldness in the stomach. The bowels are usually torpid, or affected with mucous diarrhoea; the urine is turbid, and often charged with mucus; the skin dry, contracted, and sallow; the bilious secretion deficient; and both the animal and vital functions much impaired. The temper in this variety of the disease is always very irritable, dissatisfied, morose, irresolute, and sometimes gloomy or hypochondriacal. In some instances, pain is occasionally felt in the kidneys, or neck of the bladder, and gravelly matter is dis- charged with the urine. The local consequences of inveterate or chronic gout are often ex- tremely distressing. The ligaments become thickened; the bursas mucosae indurated and enlarged; and the tendons knotty, rigid, and contracted. In some individuals, strongly predisposed to the dis- ease, earthly matter is deposited in the bursae, sheaths of the ten- dons, under the cuticle, and in the cellular membrane surrounding the affected joint. Mr. Brodie observes: "the effects of gout on the joints are very remarkable. The cartilages are absorbed; the exposed surfaces of bone are entirely, or partially encrusted with white earthy matter, which I conclude to be urate of soda; and sometimes they have the appearance of being formed into grooves, as if they had been worn from their friction on each other." Retrocedent gout.—When the gouty inflammation, either of the 408 gout. acute or chronic form, leaves its external seat, and fixes on some in- ternal organ, it constitutes what is termed retrocedent gout. This retrocession of the disease may depend either on a want of consti- tutional energy; or upon an accidental or habitual weakness of some internal organ; or finally, on cold, repelling, and debilitating appli- cations made to the external gouty inflammation. The disease may be translated to almost every internal organ; but the parts most commonly affected, are the stomach, bowels, brain, heart, and kid- neys. When an acute attack of gout passes to the brain, coma, furious delirium, or symptoms of apoplexy, speedily ensue. Paul- mier relates a case where the retrocession of gouty inflammation from the foot to the brain, gave rise to peculiar visual illusions; the patient being harassed by a confusion of horrid and ludicrous sights, which were removed in a few hours by epispastics applied to the feet.* When the stomach becomes its seat, violent and often fatal spasm of this organ, or symptoms of acute gastritis supervene. In the intestines, retrocedent gout generally gives rise to enteritis, or violent cholic. If the heart becomes its seat, symptoms of an- gina pectoris, or more commonly protracted and generally fatal syn- cope occurs. When the disease passes to the lungs, it gives rise to violent and most painful asthmatic symptoms; in the kidneys it causes nephritis; and when it fixes on the neck of the bladder, the phenomena of vesicle calculus ensue. It has been a subject of considerable controversy whether the in- ternal affection which arises from translated gout be of an inflamma- tory nature, or whether spasmodic. It is probable, I think, that the metastastic affection may assume either character, according to the structure upon which it falls, or the peculiar habit of the system. In the stomach, it appears sometimes under the form of violent and rapidly fatal spasm; and in the brain, coma and convulsions; al- though in both organs the ordinary symptoms of inflammation often occur when invaded by the disease. In the atonic and obscure form of the disease, where the gouty affection is, as it were, floating about in the system, with an occa- sional imperfect manifestation of its presence in the joints of the ex- tremities, the effects of its attacks on internal parts are not so violent and dangerous as those resulting from metastasis of the acute form of the disease, although often extremely distressing. Indeed, atonic, or irregular chronic gout, often fixes upon internal organs at once, and without the previous or concurrent appearance of external arti- cular inflammation. It sometimes locates itself in the mucus mem- brane of the urethra; giving rise to a blennorrhceal discharge, resem- bling gonorrhoea. In old and gouty habits, the mucous membrane of the bowels sometimes become affected with the gouty irritation, producing muco-purulent discharges from the rectum;t and a simi- lar discharge is still more common from the kidneys and bladders * Diet, des Science. Med. t. xix. p. 112. + Reil's Fiebrlehre, b. iii. p. 596- GOUT. 409 in such individuals. Haemorrhages from the nose, lungs, kidneys, and womb, have been known to arise from gouty irritation; and Richter observes, that haemorrhois are particularly apt to occur in gouty habits.* Various cutaneous affections depend, sometimes, on a gouty condition of the system. Richter says, " there is a gouty itch, as well as herpes, which latter is apt to appear on the parts in which the gout is wont to appear, and particularly on the wrists and the ankles." Gilbert relates an instance in which a number of fur- uncles appeared, instead of a regular attack of the disease, in a per- son who had been long subject to hereditary gout.t Chronic gouty affection of the stomach may show itself by pyro- sis; extreme sensibility of the stomach; bulmia; or total anorexia with gastralgia and flatulency. De Haen mentions a case, where the desire for food recurred at times so violently and suddenly, that if it was not immediately satisfied, severe pain in the stomach, with nausea and violent vomiting, speedily ensued. Stoll relates an in- stance of spasmodic dysphagia from gouty irritation. Chronic gout, located in the bowels, sometimes give rise to a colicky affection, with paralysis of the lower extremities, strongly resembling colica picto- num. The genital organs are occasionally affected by chronic gout, giving rise to painful and protracted priapism, and pollutions. The uterus too, often becomes the seat of gouty irritation, particu- larly about the period of the final cessation of the catamenia. " A state of chronic inflammation of the uterus ending in a kind of en- largement and induration of this organ, is occasionally the conse- quence of this affection." (Richter.) Chronic pectoral affections are extremely common in old people who have been much afflicted with gout. Cough, dyspnoea, asthma, with copious mucous expectora- tion, or occasional violent and distressing sanguineous engorgements of the lungs, (apoplexia pulmonum) are the usual occurrences in cases of this kind. It would seem too, that retrocedent gout is not unfrequently the cause of hypertrophy, ossification, and other organic affections of the heart (Kreysig.) Pott mentions a case of hydro- cele, which disappeared on the occurrence of a regular paroxysm of gout; aqd it is stated by Musgrave, that chronic gout sometimes assumes the character of scurvy. There is, indeed, scarcely any form of acute and chronic disease which may not arise from gouty irritation, and almost every organ or structure of the system may be the seat of its ravages. Diagnosis.—The only affection with which gout is apt to be con- founded is rheumatism; and there exists, indeed,a very close resem- blance between them, although sufficiently diverse, in several essen- tial circumstances, to justify their being regarded as distinct forms of disease. The principal points of difference between these two * Specielle Therapie, torn. 6. p. 571. | Diet, des Scienc. Med. torn. xix. p. 117. Vol. I.--52 410 GOUT. affections, have already been mentioned under the head of rheuma- tism, and need not therefore be repeated in this place. Causes.—Gout, unlike rheumatism, requires a peculiar con- stitutional habit or predisposition, before any exciting cause can develop the disease. This predisposition is frequently hereditary, and perhaps still more frequently acquired by certain habits of liv- ing. Where the predisposition is very strong, and this will gene- rally be the case when it is derived from both parents, scarcely any precautions in avoiding its usual exciting causes are sufficient entirely to obviate some manifestations of the disease. It. is asserted by some writers, that however considerable the gouty predisposition may be, the disease occurs but exceedingly seldom, and some assert never, before the age of puberty. Richter, however, affirms that the dis- ease sometimes, though indeed very rarely, occurs even in child- hood. This predisposition does not manifest itself in early life, by any obvious defect of constitutional vigour or health. The children of gouty parents are as apt to be strong, robust, and to possess appa- rently as vigorous digestive and assimilative powers, as those born from parents of the most healthy habits. Barthez, however, observes that the hereditary predisposition to this disease is generally attended with a peculiar physiognomical expression, by which an experienced eye may detect its existence.* The age at which gout usually first shows itself, is between the thirtieth and fortieth year. Women are much less subject to this disease than men; and in its regular and acute form, located in the feet, it is almost exclusively confined to the latter sex. When gout does occur in females, it is almost always after the period of the final cessation of the menses, and in them it usually assumes somewhat of an atonic or irregular character. Hip- pocrates observes, that eunuchs are never affected witn gout; an observation which is, however, contradicted by Dreysigtand others. The causes which are especially calculated to produce a predispo- sition to gout in habits free from a hereditary diathesis favourable to this disease, are, the habitual and superabundant use of rich, nou- rishing, and strongly seasoned articles of food, particularly animal diet; and the free indulgence in vinous or fermented liquors, in conjunction with an indolent, inactive, and luxurious course of life. Vinous liquors are much more apt to lay the foundation^ of gout than distilled alcoholic spirits; and of the former it would appear that Champaigne, claret, and port, have a considerable stronger tendency in this way than Madeira, Lisbon, and Sherry, " because in addition to their equal or greater heating effect, they give rise to more acidity in the primae viae." (Scudamore.) Dr. Rush, in re- ference to the comparative tendency of wine and ardent spirits to produce gout, observes that the effects of the latter are too sudden * Barthez. Traite des Maladies Goutteuses. Paris, an. 10. t Anfangsgr. der pract. Arzniew, p. 711, as quoted by Richter—Specielle Therapie, b. vi. p. 605. GOUT. 411 and violent to admit of their being thrown upon the extremities, and that they appear only in visceral obstructions, and a complicated train of chronic diseases. "The effects of wine," he says, "like tyranny in a well-formed government, are felt first in the extremi-' ties; while spirits, like a bold invader, seize at once upon the vitals of the constitution." Indolence, or an inactive course of life, con- tributes powerfully to the production of the gouty diathesis. Neither rich and high-seasoned food, nor the free indulgence in vinous pota- tions, are apt to produce the predisposition to gout where it is coun- teracted by a laborious or very active course of life. The principal exciting causes of gout are, intemperance in eating and in the use of spirituous liquors; suppression of habitual evacua- tions; violent or depressing mental affections; cold and humidity; redundancy of acid or bile in the primae viae; fatigue both of body and mind; intense and protracted study; external injuries; the abuse of mercurial remedies; excessive evacuations, particularly sanguineous discharges; excessive venereal indulgence; and a sudden change from an abundant and nourishing to a spare and innutritious diet. Proximate cause.—In relation to the proximate cause of gout, a very great variety of opinions have been expressed by pathologists. The hypothesis which has obtained most credit, in reference to the pathology of this disease, is that which ascribes it to a peculiar morbific matter in the blood. It has been supposed to depend on an excess of uric acid in the system; since, according to the obser- vations of Wollaston, there always exists a redundancy of this acid in gouty persons. Berthollet thought that an excess of phosphoric acid constitutes the proximate cause of the disease—an opinion to which he was led from having observed that the urine of gouty in- dividuals was much less charged with this acid during the absence of the active state of the disease than in healthy persons; but that it became abundant on the approach and during the continuance of the gouty paroxysm. Some have contended, that instead of a supera- bundance of an animal acid in the system, the materia atthritica is of an alkaline character. It is asserted by Petit, that the perspiration of a gouty patient has been known to turn the tincture of violets into gre&n colour.* The theory of Herrisant, and' in general, the identity of the nature of urinary calculi, and of gouty concretions, though apparently confirmed by the experiments of Scheele, has been fully confuted by Wollaston—since, from his experiments, it appears that gouty concretions always contain lithate of soda, which, according to Fourcroy, never enters into the composition of urinary calculi.t Scudamore has entered into an elaborate experi- mental examination of the two former of these doctrines. In rela- tion to Wollaston's hypothesis, he ascertained by experiment, that * Diet, des Sciences Med. t. xix. p. 162. r Richter's Sperielle Therapip.b. vi. p. 634. 412 GOUT. the appearance and quantity of uric acid is always connected with, and proportionate to the unhealthy state of the chylopoietic function, but neither necessarily nor regularly an attendant on gout With regard to the opinion of Berthollet, his experiments show that al- though an increased secretion of phosphoric acid in the urine occurs in the paroxysm of gout, yet the same takes place in other diseases; as for example, in diseases of the liver, and in some forms of fever. It is evident, therefore, that the chemical products which occur in gout are various, and that they are to be regarded rather as the effects of a peculiar morbid condition of the organization, than as the proximate cause of the gouty phenomena—or as furnishing any evidence of a specific gouty matter in the system. (Richter.) Without, however, referring to any other doctrines on this head, it may be observed, that disorder and debility of the digestive functions is one of the most constant precursory, as well as concomitant occur- rences of an attack of this disease. From the constant attendance of this gastric disorder, Broussais and some other writers have been led to regard the disease as primarily located in the primae viae, and as depending on a peculiar irritation in the mucous membrane of the alimentary canal. The dynamic doctrines of Stahl, Cullen, Barthez, Sprengel, and others, are even less satisfactory than those which place the proximate cause of the disease in some morbid dis- position of the blood. It can nevertheless scarcely be doubted, that some defect or derangement of the reproductive functions lies at the bottom of the evil; and that this primary dynamic disorder, in conjunction with its consequent humoral depravation, constitutes the fundamental pathological condition of the system in gout. Treatment.—The treatment of gout divides itself into that which is proper during the paroxysm, and that which is appropriate during the intervals of the fits. To obviate or postpone the re- currence of the disease after it has once made an attack, an ab- stemious course of digestible diet must be enjoined, and the use of wine and other. fermented liquors interdicted. Various reme- dies have been recommended during the premonitory stage, with the view of preventing the development of the approaching pa- roxysm, or of moderating its violence—all of which, however, are much more apt to prove injurious than beneficial, and ougit to be rejected as hazardous.* During the attack of the disease, the general treatment must be more or less antiphlogistic, according to the degree of general phlo- * The following means have been advised in the forming stage of the disease, in order to moderate or prevent the paroxysm. .Emetics, (Chalmers;) active cathartics, (Musgrave;) vegetable bitters, iron, and high-seasoned food, (Grant;) Dover's powder or antimonial wine with opium, (Fothergill;) large doses of musk or castor, (Williams;) gratiola, (Wolff;) bleeding from the foot, (Gil- bert;) the application of.very cold water to the feet, (Giannini;) the internal use of iced-water, (Barthez;) &c. GOUT. 413 gistic excitement present. Unless the system is very plethoric, and the habit vigorous and inflammatory, bleeding may be well dispensed with. Under no circumstances, indeed, can this evacua- tion be regarded in any other light than a doubtful auxiliar)7; and, when carried to a great extent, may do serious injury by favour- ing metastasis to internal organs. It is true, instances are mentioned where the local affection was speedily removed by prompt and copious abstractions of blood, without any immediate evil conse- quences; but the cases where this practice was productive of dan- gerous effects, are sufficiently numerous to demonstrate its danger- ous tendency when very actively employed. I am well aware that there are eminent authorities on the side of decisive blood-letting in this affection. Heberden, Rush, and Hamilton, insist strongly on the propriety of venesection in gout; but the present sentiment of the profession is opposed to this measure as a principal remedy; although, moderately employed, it is generally admitted to be useful under symptoms of high vascular excitement. Cathartics are decidedly beneficial in the attack of regular gout. The alimentary canal is always more or less loaded with dark- coloured, vitiated, and irritating matters, which should be as speedily evacuated as possible. Scudamore recommends the following pills —a combination which I have used with very good effect* He advises the exhibition of cathartics and diuretics conjointly, as particularly useful in the gouty paroxysm. " I have experienced the most remarkable success," he says, " from a draught composed of magnesia gr. xx.; sulphat magnesia?, 3iss.; vin. colch. 3iss. with a little sweetened water. This draught should be repeated at in- tervals of four, six, or eight hours, according to the freedom of its operation and the urgency of the symptoms." The bowels should be kept freely moved throughout the paroxysm.t Emetics also have been recommended in the treatment of gout; and where the symptoms of redundancy of acid, or bile, or other of- fending matters in the stomach, are unequivocal in the commence- ment of the disease, advantage may, no doubt, be obtained from the administration of an emetic. As a general rule, however, emetics are inappropriate in this affection. They are indicated when there is much nausea, vomiturition, acidity in the stomach, with a furred and foul tongue, or where the disease supervenes soon after a hearty meal.* Ipecacuanha should be employed for this purpose in prefer- ence to antimony. * R.—Extract, colocynth. compos, jss. Calomel gr. 15. Tart, antimon. gr. i.—M. Divide into sixteen pills. S. Two or three to be taken on going to bed. X Boerhaave, Warner, and some other writers, reject purgatives wholly from the list of remedies proper in this disease; but their apprehensions in this respect are without foundation. 414 GOUT. For the purpose of keeping up a gentle diaphoresis, we may em- ploy opium in combination with calomel and tartar emetic with much advantage, after the bowels have been freely evacuated by purgatives. A grain of opium with the same quantity of calomel and one-tenth of a grain of tart, antim. may be given every four or six hours—assisted by copious draughts of infusion of elder flowers, or of eupatorium perfoliatum. I have used the diaphoretic mixture, given at page 176 of this work, with the addition of a drachm of laudanum, with excellent effect. To moderate extreme suffering from the gouty inflammation, and to procure the patient some repose, opium, under proper manage- ment, is both a safe and a highly useful medicine. " On many occasions," says Scudamore, " when the patient has described the pulsatory throbbing of the inflamed part to resemble almost the successive blows of a hammer, when the heart has been in inordinate action, and the inflammatory diathesis has appeared altogether urgent, I have stood by the bed-side and witnessed the happy power of a free administration of opium, in causing an abate- ment of the action of the vessels, and producing universal tranquil- lity in a short time." I have myself employed opium in this affec- tion with the happiest effect. Not only is the extreme pain al- layed, but the sympathetic febrile excitement also is generally con- spicuously moderated by full doses of this narcotic. The bowels should be freely evacuated before recourse is had to this medi- cine. It may be given in doses of one grain, either by itself or as mentioned above, with calomel and tart, antim. every hour or two until the local pain is allayed. When opium disagrees with the stomach, the black drop, or the liquor opii sedativus of Dr. Battley, should be employed.* A great number of specifics and nostrums have at different times acquired a temporary reputation for their usefulness in this disease; of which, however, a few only need be mentioned. The colchicum autumnale, which would seem to be the hermo- dactyl of the ancients, is now universally admitted to be an article of great powers in removing gouty inflammation. It is not, how- ever, admitted on all hands to be a very safe remedy; for, it is asserted by some, "that it is apt to leave the predisposition to the disease much stronger in the system; to lead to the still more cala- mitous, because still more constant, pains of the chronic form of the disease." (Scudamore.) That the objections which have been urged against this article are altogether unfounded, I am not disposed to affirm; but I think it highly probable, that much of the harm which has been ascribed to it has arisen from the improper or inordinate use of the remedy. 1 have used it in about a dozen instances with * Opium is very favourably mentioned as a remedy in this disease, with the view of moderating the patient's sufferings, by Sydenham, Warner, and Richter. GOUT. 415 marked advantage, and so far as I have ascertained, without any pre- judicial consequences whatever. Even Scudamore, whose objection to this article I have just quoted, observes, that under judicious ma- nagement it may be employed with perfect safety, and almost always with decided benefit. He gives it with magnesia and Epsom,salts, according to the formula mentioned in the preceding page. I have usually directed from 30 to 50 drops of the vinous tincture with about 20 grains of magnesia, to be taken every six hours until it acts on the bowels. When it produces nausea, or other unpleasant sen- sations in the stomach, its use must be discontinued. The eau medicinale is a celebrated nostrum, which has been ex- tensively used in France; and its powers of shortening the paroxysm are said to be surprisingly great. It is now generally admitted, however, that in its ultimate consequences it often proves highly injurious. When first used, it rarely fails to remove the gouty in- flammation speedily; but its powers in this way are gradually dimi- nished by repetition—producing at last great derangement of the digestive functions, permanent nervous irritation, giddiness, trem- bling, coldness, and oedema of the extremities, and other manifesta- tions of infirm health. The tincture of white hellebore and laudanum has also been found promptly efficient in removing gouty inflamma- tion, but it is said to be as pernicious in its consequences, and even more so, than the eau medicinale. Local remedies.—Various local applications have been employed in the treatment of gouty inflammation; but the majority of them are useless, and indeed often prejudicial. Neither leeching, nor blistering, nor warm pediluvium, appear to be calculated either to relieve the pain, or to promote the resolution of the local affection. Leeching even sometimes increases the pain. Some have advised the application of cold water to the inflamed joint—a measure which will, indeed,often moderate the pain and inflammation, but its par- ticular tendency to cause a retrocession or translation of the dis- ease to internal organs, renders it objectionable.* Scudamore ob- serves, that the best local applications are such as are volatile and stimulating. He strongly recommends a liniment composed of one part of alcohol and three parts of mistura camphorata, which is to be applied to the affected part in a lukewarm state, by means of seve- ral folds of linen strips saturated with it. I have employed this lotion in several instances with decided benefit. Its good effects were manifested by a speedy mitigation of the heat and pain of the affected part. The application of ether will also afford relief by its rapid evaporation, and consequent subduction of the heat and local excite- ment of the inflamed joint. Wrapping the part in flannel was formerly regarded as the most * The practice of applying cold water to the inflamed joint in gout is recom- mended by Hippocrates—(Aphor. sect, v.)—Kinglake employed cold poultices. Med. and Phys. Journal, No. 24. 416 GOUT. safe and beneficial application; but "flannel and patience" have very properly grown out of fashion; for this application tends to protract the paroxysm, and to aggravate the sufferings of the patient, without affording any peculiar advantages as to the future health of the patient. Where there is slight or incomplete development of the gouty inflammation in the extremities, with a tendency to retro- cession, benefit may, no doubt, be derived from the application of flannel or cotton to the part; but, in the regular and fully developed attack, it is at best useless, and often distressing.* During convalescence after an attack of gout, a temperate and moderately nourishing diet, with regular exercise and the occasional use of mild laxatives, should be enjoined. When the biliary and digestive functions remain disordered, which is very commonly trie case after violent and protracted paroxysms, small doses of blue pill in the evening, with an occasional laxative and a weak infusion of colomba or gentian in small but repeated doses during the day, should be used.t To remove the protracted swellings which some- times remain, stimulating liniments may be usefully employed; or, as Scudamore recommends, a flannel roller applied to the affected part. The remedies or prophylactic means that have been recommended during the intervals of the paroxysm, with the view of moderating the gouty diathesis, or of preventing the recurrence of the disease, are very numerous. Little or no dependence, however, is to be placed on any measures in this respect, except on such as are calcu- lated to restore the healthy action of the stomach, liver, and skin; and especially on the adoption of proper regulations, with regard to diet and exercise. Abstinence from high-seasoned and very nourishing diet, and from all kinds of fermented liquors, with regu- lar exercise in the open air, a constant attention to the maintenance of the healthy action of the bowels, liver, and skin, by the occasional use of laxatives, blue pill, and weak infusions of some of the tonic vegetable bitters; and the wearing of flannel next the skin, will, per- haps, do all towards resisting the progress of the disease that can be effected by remediate means. According to the experience of Scu- damore, the ammoniated tincture of iron, commencing with 20 drops twice daily, and gradually increasing the dose to 60 drops, is an ex- cellent tonic during the intervals of the gouty paroxysm. In the treatment of the chronic form of the disease, the principal * A great variety of other local remedies have been favourably mentioned— namely, the warm steam-bath, (Percy;) the split leaves of the cactus crocus, emplast. hyoscyam. spread on oiled silk, (Thilenius;) emplast. opii; cataplasms of conium, belladonna and hyoscyamus, and moxa. X As an aperient during convalescence from gout, Warner's gout cordial is an excellent remedy. The formula for makiug this tincture is as follows: R.— Rhubarb §i. senna gss. saffron gi. liquorice root giv. raisins Ibi. brandy Ibiii. Digest for a week, and strain. GOUT. 417 attention must be directed to the chylopoietic organs. A light and digestible diet, with an occasional blue pill in the evening, followed in the morning by a gentle laxative, are among the most useful re- mediate measures in this variety of the disease. To relieve the nervous irritation and pain, generally so distressing during the night, we may give one or two grains of opium, or from 15 to 20 drops of black drop at bed-time. Scudamore recommends lactucarium and stramonium in combination, as a very useful narcotic in such cases. Opium in union with camphor, forms also an excellent anodyne in instances of this kind. The carbonate of ammonia, or from 20 to 30 drops of a solution of camphor in sulphuric ether, Oiii. of camph. to |i. of ether) or warm ginger-tea, may be usefully admi- nistered, to relieve the spasmodic and nervous pains in the stomach, which are so common in the chronic form of gout. A vast variety of remedies have been recommended for the removal or mitigation of chronic arthritic affections. Amongst these, however, there are very few that are worth being mentioned. Gumguaiacum; ol. tere- binth; calamus aromaticus, (Rave, C. L. Hoffman;) and particularly the vegetable bitter tonics; aconitum, (Richter;) the bark of the prunus padus, (Horn's Archiv. 1812;) chalybeates; herba rhodo- dend. chrysanthi; belladonna; mercurial remedies; and the use of sulphurous mineral waters, are the principal articles of this kind. Rave, a German writer, speaks in very favourable terms of savin (juniperis sabina) in chronic gouty inflammation of the joints.* I have known much benefit derived from this article in chronic or subacute arthritic affections, more especially in subacute rheumatic inflammation. Rave recommends the following formula for taking the savin.t In an atonic, torpid, or sluggish state of the system, with chronic gouty symptoms, the following composition, recom- mended by Quarin, will sometimes act very beneficially.^ Alka- line remedies have also been supposed peculiarly adapted to coun- teract the gouty diathesis, but they appear to be of little or no value in this respect. Formerly, the liquor antiarthriticus Elleri was much in vogue as a remedy in chronic gouty affections. It consists * Beobachtungen und Schlusse aus der praktischen Arzneywissenschaft. Von Alexander Rave. Munster, 1796. X R.—Herb, sabin. recens. ^ii. Tinct. antimon. acris. ^vi.—M. digere per 3 vel 4 dies. Or—R.—Pulv. hb. sabin. recens. sjss. Antim. crud. gr. xii. Flor. sulp. gr. xv. Camphor, gr. iv.—M. f. pulv. pro dos. This dose is to be taken twice or thrice daily. X R.—Flor. sulph. gi. Resin, guaiac. gss. Antim. crude ^iii.—M. f. pil. pondere gr. iii. S. Take from six to eight pills, three times daily. Vol. I.—53 418 CATARRHAL OPHTHALMIA. of equal parts of sulphuric ether and aq. ammon. succinata. The dose is from 30 to 40 drops. When the gouty inflammation leaves its external seat, and fixes on some internal organ, prompt and active remediate measures are necessary to obviate the immediate danger. Cullen recommends heating and stimulating remedies in retrocedent gout; where the disease attacks the stomach, this, without doubt, is often the best practice. Laudanum in large doses, (from 80 to 100 drops) with warm spiced brandy, should be freely administered; and a large sinapism applied over the region of the stomach. Opium, in the form of tincture, is a most valuable medicine in cases of this kind. Even where the translated affection assumes the character of acute gastritis, and where the aromatic and diffusable stimulants are im- proper, the greatest relief will often follow the exhibition of large doses of this narcotic. When the brain becomes the seat of the translated disease, stimulants and opiates are inadmissible. In such cases, our principal reliance must be placed on the speedy and copi- ous abstraction of blood, together with the use of active mercurial cathartics, cold applications to the head, and sinapisms to the feet. In all instances of translated gout, stimulating or rubefacient appli- cations to the feet are decidedly indicated. Irritating purgative enemata also are useful, as well as cupping and leeching over the region of the affected organ. —~»»©@8«..— CHAPTER XVI. OF THE INFLAMMATORY AFFECTIONS OF THE EYES. 1. Catarrhal Ophthalmia. This is the most common form of ophthalmia in adults, and pro- ceeds, as its name imports, from the influence of atmospheric vicissi- tudes, and especially from cold and damp night air. The inflamma- tion in this variety of the disease is confined chiefly to the conjunc- tiva and the meibomian glands. The patient complains of pain, into- lerance of light, and a constant sensation of sand in the eye— which latter feeling may, according to Mr. Mackenzie, be regarded as a diagnostic symptom of this variety of ophthalmia.* In mild cases, the redness of the eye is not very great, and is most conspi- cuous in the conjunctiva lining the eyelids. The flow of tears is always much increased; and in severe cases, the secretion often be- comes opaque and purulent. Chemosis sometimes takes place in very * Med. and Phys. Journal, No. 4,1826. CATARRHAL OPHTHALMIA. 419 violent instances, and the cornea may burst and destroy vision. The headach in this variety is seldom very severe, and the febrile excite- ment is generally mild, and in slight cases altogether wanting. Treatment.—In mild cases of this variety of the disease, general blood-letting is rarely necessary or useful. In instances attended with considerable constitutional irritation, a sufficient quantity of blood should undoubtedly be drawn, to moderate the excessive momentum of the circulation. Leeching rarely affords any decided advantage; when local depletion is desired, cupping on the back of the neck and over the temples is preferable. Mr. Travers condemns scarification of the conjunctiva, and bleeding from the angular vein, in the acute form of the disease, although highly beneficial in the chronic. Nevertheless, when chemosis occurs, and the discharge becomes puriform, considerable advantage will, in general, result from scarifying the conjunctiva of the eyelids. " One or two deep incisions being made along the inner surface of the upper or lower eyelid, a very considerable discharge of blood will immediately take place, and prove a valuable means of cure in cases of this kind. The eyelid, after the incision, ought to be alternately everted and permitted to return to its natural position, by which means the divi- ded vessels are refilled, and thus a continued flow of blood be pro- duced." (Mackenzie.) In cases of this character, considerable bene- fit often accrues from the use of nauseating doses of tartrate of anti- mony, given at short intervals, so as to keep up a continued and uni- form impression. Cathartics are indispensable in this affection. The bowels must be freely opened by a full dose of calomel and jalap, or by active doses of the neutral purgative salts, and kept in a loose state through- out the course of the disease. The usual astringent lotions do no good in this variety of the dis- ease; indeed, they often prove manifestly prejudicial. The solutions of sulphate of zinc or of acetate of lead, so commonly used in in- flammations of the eye, seldom fail to increase the redness of the conjunctiva and the sensation of sand in the eye. The same obser- vation applies to cold applications; for, although they generally pro- duce temporary ease, " they are followed by reaction, with an in- crease of heat and pain." (Travers.) In the acute stage of the in- flammation, benefit will frequently arise from the use of warm sooth- ing fomentations to the eye. A weak infusion of poppy, or simply warm water and milk, may be used for this purpose. Emollient and soothing warm applications must not, however, be continued too long; for they tend to relax and to produce oedematous elevation of the conjunctiva. When the disease early assumes an atonic or almost solely congestive character, a few drops of the vinous tinc- ture of opium, or of solutions of zinc, or nitrate of silver, will often afford much relief. The nitrate of silver is decidedly the most effectual local application in this variety of ophthalmia. Four grains of this article dissolved in an ounce of distilled water, forms a solu- 420 CATARRHAL OPHTHALMIA. tion of a proper strength; " a large drop of which is to be applied to the eye by means of a camel-hair pencil. The instant that it touches the eye, the salt is decomposed, and the silver precipitated over the conjunctiva in the state of a muriate."* An abatement of the pecu- liar sensation of sand and of the inflammation, almost uniformly soon follows the application of this solution. I have myself employed the nitrate of silver in this way with almost uniform advantage. Mackenzie recommends also a solution of one grain of corrosive sublimate in eight ounces of water as a collyrium, to be used, milk warm, thrice daily, for fomenting the eyelids by means of a fine piece of linen, and allowing a few drops to pass into the eye. In cases of great severity, where the secretion is puriform, he directs " this collyrium to be injected over the whole surface of the conjunc- tiva, and especially into the upper fold of this membrane, by means of a syringe." An ointment made " by levigating twelve grains of red precipitate till they become an orange-coloured impalpable powder, to which an ounce of fresh butter is to be added, forms also a very useful appli- cation in this variety of ophthalmic disease." A very small portion of this ointment is to be applied along the edges of the eyelids at night on going to bed. Kopp speaks very favourably of the tincture of galbanum as a local application in ophthalmic inflammation. A compress of linen is to be moistened with this tincture and laid over the closed eyelids. I have used this application with marked benefit in several cases, after the acute stage of the inflammation had in a degree subsided. In some instances of a general irritable habit of body, the ophthal- mia will continue to grow worse under the ordinary depletory mea- sures, " the irritability increasing as the strength fails." In cases of this kind, recourse must be had to calomel and opium in combina- tion, or opium with small doses of tart, antimony or ipecacuanha. From three to four grains of Dover's powder with the sixth of a grain of calomel, may be given every three or four hours, at the same time that the above exciting applications are made to the eye. Blistering on the back of the neck, particularly after proper deple- tion, will almost always assist materially in the reduction of the in- flammation. In violent and protracted cases of the disease, the inner surface of the upper eyelid sometimes becomes rough, with a species of hard fungoid elevations, resembling a state of sarcoma of the conjunctiva. Where this occurs, it should be lightly touched with lunar caustic or a piece of sulphate of copper—the eyelid being held up from the eyeball for a minute or two after the application. Ophthalmia sometimes assumes a strictly periodical form. The attack in such cases is usually attended with intense suffering; and under the usual antiphlogistic plan of treatment is apt to continue a * Mackenzie, loc. citat. RHEUMATIC OPHTHALMIA. 421 very long time. In instances of this form, leeching, blood-letting, and cooling applications, never fail to do harm. The appropriate means consist of the same remedies that are employed in intermit- ting neuralgia, or in the ordinary intermitting fever; and there can exist but little doubt that all these forms of periodical disease are congeneric affections. Quinine, bark, and arsenic, will, in general, speedily arrest the progress of the present variety of ophthalmia.* 2. Rheumatic Ophthalmia. This variety of ophthalmic inflammation is chiefly characterized by violent circumorbital pain, extending to the temples, teeth, lower jaw, and internal ear. The pain is continuous, with occasional fits of aggravation, and is almost always much more severe at night than during the day. The white of the eye is of a yellowish red tinge, terminating abruptly at the cornea—which latter becomes dull, cloudy, and as the disease advances, more opaque in the centre than at the circumference. According to the observations of Travers, " rheumatic ophthalmia presents a zonular arrangement of the ves- sels, more or less cloudiness of the aqueous humour, and a pupil dis- placed or drawn a little to one side." The flow of tears is at first diminished; but in the course of the disease it becomes copious. In most instances, slight abrasions of the conjunctiva and cornea occur; but these are generally so minute and superficial as readily to escape observation, unless closely inspected. In violent and protracted cases, the cornea is sometimes destroyed by ulceration, and pus is secreted within the chambers of the eye. The inflammation, in this variety of the disease, is confined chiefly to the fibrous structures of the eye and of the surrounding parts; and partakes in this respect of the character of rheumatism. It is excited by the same causes that give rise to the catarrhal variety; and occurs most commonly in persons of an arthritic or rheumatic dia- thesis. It is also particularly apt to occur from the influence of cold while the system is under the operation of mercury, or soon after the mercurial action has subsided. " It is often seen in company with, or following gonorrhoea, eruptions, or sore throat of a pseudo- syphilitic character, and the pains are allied to those which succeed to the exhibition of mercury, t Treatment.—Bleeding very rarely affords any obvious advan- tages in this variety of ophthalmia. When the pulse is very active, it should, nevertheless, be moderated by venesection, in order to lessen the general phlogistic diathesis, and thereby favour the bene- ficial operation of the more appropriate remedies. Much advan- tage may sometimes be derived from one or more antimonial eme- * For an interesting case of this kind, see Journal Complement. Jan. 1830. See also Med. Chir. Rev. March, 1830. X Travers—A Synopsis of the Diseases of the Eye, &c. p. 129. 422 PURULENT OPHTHALMIA. tics in the early stage of the disease; and active purgatives are equally important. After the alimentary canal has been well eva- cuated, we may exhibit a solution of tart, antimon. in nauseating doses, every two or three hours; or antimonial powder in combina- tion with opium and calomel, so as to keep up a uniform, conti- nued, moderate diaphoresis.* I have known much good done in this variety of the disease by repeated small doses of Dover's powders. Cupping or blistering the nape of the neck is a useful auxiliary; and fomentations with an infusion of poppy heads, always mitigates the pain very considerably. One of the most soothing applications to the eye, is a few drops of an aqueous solution of opium put into it several times a day, or a solution of the sulphate of morphia. Punc- turing the cornea, so as to give exit to the aqueous humour, is al- most always soon followed by an abatement of the inflammation and pain. The usual astringent and exciting collyria are wholly inapplicable in the treatment of this affection, and almost uniformly do injury. Mr. Wardrop recommends the internal use of cinchona in very small doses, (from five to eight grains,) if the tongue remains white after the bowels have been freely evacuated. Would not the tincture of colchicum be beneficial in this affection? 3. Purulent Ophthalmia. Acute suppurative inflammation of the conjunctiva is the most dangerous variety of ophthalmia, and generally the most difficult to manage. It occurs, however, under every grade of violence, from a mild and simple to a most severe and rapidly destructive affection. The severer cases come on suddenly, and are from the beginning attended with very severe darting pains through the eye. The eye- lids swell rapidly, and often to an enormous extent,—the upper one being often so much enlarged as to rest upon the cheek. The con- junctiva also becomes so much swollen by infiltration and distention of its vessels, as to rise up in an ennular mass of red spongy granu- lations, overlapping the cornea so as almost to conceal this part. A very copious purulent secretion from the inflamed conjunctiva takes place soon after the disease is developed—and which usually issues in large drops from under the swollen lids. The edges of the eye- lids are sometimes so closely pressed against each other, as to con- fine the matter until it accumulates and distends the lids into a large round tumour, and at last bursts forth and runs down the cheek. The pain in the head is always extremely severe, and the whole system sympathizes strongly with the local affection—the accom- panying fever being of a high synochal grade, suffering conspicuous exacerbations in the evening. Under judicious treatment, this se- vere form of the disease usually begins to decline about the third or * R.—Pulv. antimonialis Qi. Calomel gr. iii. Pulv. opii gr. iiss.—M. Divide into nine equal parts. Take one every three hours. PURULENT OPHTHALMIA. 423 fourth day, and gradually subsides until the health of the eye is re- stored. Cases of great severity, or where the treatment is inefficient or improper, often terminate rapidly in more or less disorganization of the eye and consequent loss of vision. Sometimes every part of the ball of the eye becomes disorganized by suppuration. Much more commonly, however, the consequences are not so destructive,— a greater or less degree of opacity and thickening of the cornea, or ulcerative destruction of this part, being usually the result of the inflammation. In some instances, ulceration of the proper substance of the cornea takes place beneath the conjunctiva—this membrane remaining entire. (Travers.) This " interstitial" ulceration of the cornea, says the author just referred to, may be either acute or chronic. The acute variety is often crescent-shaped, and passes nearly across the whole cornea. In consequence of the absorption or abrasion of the conjunctiva, directly over the ulceration of the cornea, great pain is caused by the motions of the upper eyelid. The chronic interstitial ulcer occurs in debilitated subjects, remain- ing often a long time like a slight depression or excavation on the surface of the cornea, the restorative action of the vessels of the part being inadequate to repair the lost structure. Gangrenous destruc- tion of a greater or less extent of the cornea may also take place in suppurative ophthalmia. In the milder variety of purulent ophthalmia, there is little or no danger of destruction of the cornea, unless injury be done by stimu- lating applications. Mr. Travers says, " that a very slight haze of the cornea is the worst direct result of the mild form of the disease." In cases of this kind there is neither the intense pain, nor the ex- cessive swelling of the lids, which characterize the violent acute form of the complaint. There appear to be different varieties of suppurative ophthalmia, in relation to the exciting causes of the affection. The Egyptian ophthalmia, which is the most violent form of this disease, is ascribed to the combined effects of vicissitudes of atmospheric temperature and humidity, a hot wind loaded with fine particles of sand, and a bright and piercing light of the sun. A violent form of purulent in- flammation of the conjunctiva, is also excited by the application of gonorrhoeal matter to the eye; and it is said, by metastasis of gonorrhoeal inflammation from the urethra to the conjunctiva. In- fants also are subject to purulent ophthalmia; but in them the dis- ease is generally much less serious than in adults. Mr. Gutherie states that there are two varieties of infantile suppurative inflamma- tion of the eyes: "one affecting the conjunctiva of the lids only, the other implicating the eyeball." I have repeatedly noticed these distinctions m the ophthalmia of infants; and although little or no permanent injury need be apprehended from the former vari- ety, I have found it even more difficult to subdue than the latter. Some writers attribute this affection in infants to intestinal irritation from bile and sordes in the primae viae; but the opinion of its being 424 PURULENT OPHTHALMIA. almost universally the consequence of the direct application of some morbid secretion to the eyes at the time of birth, is, I think, by far the most probable. 1 have never known a single instance of this disease occurring in infants, soon after birth, where, upon inquiry, I did not learn that the mother had been affected with leucorrhoea, or some other morbid vaginal secretion. The fact, too, that the oph- thalmic discharge in cases of this kind, is capable of exciting the same disease when applied to the eyes of others, furnishes a strong argument in favour of this etiology. Mr. Ryall, whose opportuni- ties for observation on this subject have been very extensive, states that he has repeatedly known the ophthalmia excited in nurses, " by the accidental application of the matter from the infant's eyes to their own."* Purulent inflammation of the eyes occurs, no doubt, occasionally in infants as in adults, from cold, and various irritating causes, acting directly on the eyes; but this is comparatively, per- haps, but very rarely the case. Treatment.—In mild cases, where the swelling, pain, and puru- lent secretion are not great, general blood-letting is not often ne- cessary. In the severer form of the complaint, however, prompt and very decisive bleeding is indispensable to success. In those vehement cases, where the swelling of the lids is very great, the purulent secretion copious, the pain intense, and the pulse hard and frequent, "the instant relief," says Mr. Travers, " of a large vene- section, is indescribable. The pain is mitigated if not removed, the pulse softened, and the patient sinks into a sound sleep, and per- spires freely. Upon inspection we observe the high scarlet hue and bulk of the swollen and fungoid conjunctiva sensibly reduced, and the cornea has a brighter aspecf't It is frequently necessary to repeat the venesection several times in the course of the first twen- ty-four hours, before permanent impression is made on the disease. In the disease, as it occurs in infants, blood must be abstracted by a few leeches applied to the external angle, or under lid of the eye; and the eye should be frequently fomented with a decoction of poppy heads, a portion of which is to be injected under the lids to wash away the purulent secretion. Minute portions of calomel in union with ipecacuanha, or pulvis antimonialis, with an occasional dose of castor oil, should be given to infants labouring under this aff'ection.J Topical bleeding, after the vigour of the arterial action has been moderated, by a very efficient abstraction of blood from the arm, will generally assist materially in reducing the local inflammation. From 20 to 30 leeches may be applied to each temple and around * Dublin Transactions, vol. iv. f Travers, loc. cit. p. 265. X &•—Calomel gr. ii. Pulv. antimonialis gr. viii.—M. Divide into eight equal parts. S. Give one every four hours. PURULENT OPHTHALMIA. 425 the eye. Blistering on the nape of the neck, is also a very useful auxiliary; but decisive blood-letting should precede the application of the blister. One of the first and most important remediate mea- sures, is the exhibition of an active mercurial purge, and the bowels must be kept freely moved throughout the active stage of the dis- ease, by the'daily use of full doses of one of the neutral purgative salts. No nourishment except the simplest mucilaginous fluids, or toast-water, must be allowed; and in very vehement and rapid cases, total abstinence from any nutrient ingesta should be enjoined, dur- ing the first two or three days. Along with blood-letting and active cathartics, nauseating doses of tartar emetic are, in general, decidedly beneficial. They should be given in small doses every hour or two, so as to keep up a continued impression on the stomach. During the acute period of the inflammation, emollient fomentations, such as warm water, or infusion of the white poppy heads, will assist in mitigating the pain and promoting resolution; but all astringent and cooling applications are injurious. By the prompt and active em- ployment of these antiphlogistic measures, the pain, irritation, and swelling usually begin to subside about the third or fourth day, and the discharge becomes gleety at the same time that the conjunctiva assumes "a pale and flabby appearance." If, when the inflamma- tion has thus in part subsided, the cornea appear clear and bright, nothing need be apprehended as to the safety of the eye. Recourse must now be had to the exhibition of tonics and astringent and invi- gorating collyria. It would appear from the experience of Mr. Var- lez, surgeon of the Military Hospital at Brussels, and of Mr. Guthe- rie, that the chloruret of lime, forms the best local astringent appli- cation we possess in this variety of ophthalmia. The former of these surgeons, states that he has employed this article in more than four hundred cases of purulent ophthalmia with uniform success. After the local and general inflammatory condition is moderated by decisive depletion, a solution of this salt is to be applied to the in- flamed conjunctiva. He usually employed it in the proportion of a scruple to an ounce of distilled water; but when the inflammation continues, and when the patient bears it without complaining, it may be used, he says, to the extent " of three or even four drachms in the same quantity of water."* It has been found equally benefi- cial in the purulent ophthalmia of infants. In two cases of this variety of the disease, I derived the most signal advantage from injecting into the eye a solution of 10 grains of the chloruret of lime to an ounce of water, repeated three times daily. The nitrate of silver, in the proportion of from two to four grains to an ounce of water, forms also an excellent local astringent in this affection. A few drops of this solution should be introduced into the eye twice daily. In the purulent ophthalmia of infants, after leeching, emollients, purging, and antimonials, have been employed, a weak solution of * London Med. and Phys. Jour. 1827. Vol. 1.—54 426 SCROFULOUS OPHTHALMIA. this article injected under the eyelids, is generally soon followed by the most favourable effects. Mr. Ryall says, that when the "discharge becomes profuse, assuming a greenish colour, all warm fomentations and cataplasms must be laid aside, and a solution of the nitrate of silver, in the proportion of two or three grains of the mineral to an ounce of distilled water, should be frequently and briskly injected between the lids."* Various other astringent and exciting lotions have been recommended after the acute character of the inflammation has been subdued. A weak solution of alum, one grain to an ounce of water, is recommended by Travers. Others advise the application of alum-curds confined between two folds of thin linen; and Ware speaks favourably of the following solution: R.— sulphat. cupri. bol. arm. aa gr. viii. camphorae gr. ii. misce et affunde aq. bullient Jviii. At first a drachm of this solution must be mixed with an ounce of water, and injected forcibly under the eyelids; the strength being gradually reduced in proportion as the inflamma- tion subsides. M. Jahn, of Meinengen, speaks very favourably of a solution of the chloride of gold, as a collyrium in the purulent ophthalmia of children. He says it is equally beneficial in scrofu- lous, gouty, and rheumatic inflammation of the eyes. He uses it ac- cording to the following formula.! Tonics, such as the cinchona or quinine, with the sulphuric or nitric acids, must be employed to sustain the patient's powers, after the inflammation has been reduced, and the conjunctiva appears pale and flaccid. " If, whyn the lowering practice has been pushed to the extent of arresting acute inflammation, the patient being at the same time sunk and exhausted, the cornea shows a lack-lustre and raggedness of its whole surface, as if shrunk by immersion in an acid, or a gray patch in the centre, or a line encircling or half encircling its base, assuming a similar appearance, the portion so marked out, will infallibly be detached by a rapid slough, unless by a successful rally of the patient's powers, we can set up the adhesive action so as to preserve in situ, that which may remain transparent." (Travers.) 4. Scrofulous Ophthalmia. This variety of the disease occurs most commonly in children, and is frequently the first manifestation of the scrofulous diathesis. Its most characteristic symptoms are: extreme sensibility of the retina tctJie impressions of light; profuse serous secretion or flow of tears; and a mucu-purulent secretion from the glands of the tarsi, which, during sleep, agglutinates the eyelids. The pain is not often great, unless a bright light is suffered to fall upon the eye; nor is * Dublin Transactions, &c. vol. vi. X R—Chloride of gold gr. ii.; distilled water gvi. Two or three drops of this solution must be instilled into the eye, and a compress wet with it applied over the eye. Rust's Magazine, vol. xxviii. SCROFULOUS OPHTHALMIA. 427 the redness of the conjunctiva generally very conspicuous. In recent and acute cases, effusion of serum sometimes occurs around the cor- nea, " elevating the conjunctiva into a circular vesication, about a line or more in breadth, frequently occupying the entire margin of the cornea, and exhibiting a peculiar reddish brown appearance."' In many instances of this acute character, minute vesicles appear scattered over the cornea and the conjunctiva of the sclerotic coat " These pustules vary in size, according to the part of the conjunc- tiva on which they appear, being commonly smallest on the cornea, and increasing as they approach the angle where that membrane is reflected over the inner superficies of the lids, and may be considered as a distinguishing symptom of this disease." (Jeffries.) These vesi- cles break, in some cases, and form ulcers; and if the inflammation be not checked, these ulcerations often gradually penetrate deeper into the cornea, until they form an opening into the anterior cham- ber, and give exit to the aqueous humour. The disease does not, however, often occur in this acute form, the majority of instances met with being of a strictly chronic character, the vessels of the conjunctiva " remaining in a state of passive con- gestion and engorged with red blood," with small indolent ulcera- tions, or nebula of the cornea, attended with a constant profuse flow of tears, and with such distressing intolerance of light, that the patient keeps the eyes constantly closed, and lies with the face downwards, or keeps the hands continually applied over the eyes to exclude the light as much as possible. In many instances of this chronic variety of the disease, tinea ciliaris and lippitudo occur; small pustular ulcerations appearing along the roots of the eyelashes, from which a mucu-purulent fluid exudes, by which the edges of the eyelids are glued together; or the edges of the eyelids are red, and excoriated. Mr. Christian, consulting surgeon of the Liverpool Ophthalmic In- firmary, has described a variety of scrofulous ophthalmia, which he calls porriginous, from the disease being usually preceded by a por- riginous "eruption of pustules on the face and head." These pus- tules go through the various stages of suppuration, ulceration, and desquamation; and if the eruption in its pustular form, shall have disappeared before the inflammation of the eyes have commenced, still there will almost always be found some traces of the original disease in the form of scabs, or fissures behind the ears, at the com- missures of the palpebrae, or at the junction of the ali nasi with the cheeks, "t This appears to be the same variety of scrofulous ophthalmia, that has been described by Mr. Wardrop, under the name of exanthema- tous ophthalmia. Mr. Wardrop considers it as specifically distinct from the scrofulous form of the disease, though he admits that it * Cases of Surgery, &c. &c. By Henry Jeffries, Esq. senior surgeon to St. George's and St. James's Dispensary. Lond. 1820. X Glasgow Medical Journal, No. i. 428 SCROFULOUS OPHTHALMIA. very frequently occurs in subjects of a scrofulous habit. Neither the symptoms nor the treatment of this disease, however, differ so materially from those peculiar to scrofulous ophthalmia, as to justify the opinion that they are essentially distinct in their characters. " Eruptions of the scalp and discharges behind the ears, so frequent in children, are the affections with which this ophthalmia is most commonty connected. These diseases alternate with the disease of the eyes, the latter becoming affected when the eruption or discharge disappears; whilst when either of these returns, the eyes recover. This ophthalmia also sometimes succeeds measles, scarlet fever, and other exanthematous diseases, but usually appears a considerable time after these affections have subsided. The symptoms of the ex- anthematous ophthalmia are very characteristic; for, besides being connected with eruptions and confined to young people, the exces- sive intolerance of light, the enormous secretion of tears, and the relief from forcibly squeezing the eyes, are symptoms quite peculiar. The patient can scarcely hold up his head, and if he is desired to open his eyes, he is affected exactly as if he were looking on a mir- ror, reflecting a bright sunshine, every attempt causing a profuse gush of tears, and being instantly succeeded by a violent and invol- untary squeezing of the eyelids and knitting of the brows. He ex- cludes all light, not only by holding down his head and squeezing the eyelids together, but by pressing a handkerchief firmly on them, or by resting his face against a chair in some dark corner of the room. The intolerance of light is always most severe in the morn- ing; but in the afternoon it sometimes remits so much as to allow the patient to open his eyes and see to a very considerable degree for some hours. The tears are of an acrid and irritating quality, so that the cheeks, alae of the nose and lips often become inflamed, swelled, and sometimes covered with pustules and cutaneous ulce- rations."* Now this very graphic account of the symptoms, answers in every particular to the descriptions given by authors of scrofulous ophthalmia, and it certainly describes the disease which I have al- ways considered as the strumous, or scrofulous form of ophthalmia. Treatment.—General bleeding rarely becomes necessary in stru- mous ophthalmia. In recent and acute cases, however, leeching should be occasionally practised, until the pain, irritation, and in- flammation are moderated. Purgatives are indispensable in this affection, where the abdomen is tumid and tense, and the alvine dis- charges of an unnatural character. Calomel, combined with rhu- barb or jalap, should be given every two or three days, in doses sufficient to cause pretty copious purging; or a few grains of calo- mel may be taken in the evening, and followed next morning by a dose of castor oil, or of senna infusion. This active cause of purga- tion should be continued until the quality of the alvine evacuations * Transact. Med-Chirurg. Society of Edinb. vol. ii. SCROFULOUS OPHTHALMIA. 429 is manifestly improved. After this has been effected it will be suffi- cient, in general, to administer a moderate dose of calomel and rhu- barb every four or five days. In the more chronic form of the dis- ease also, active purgation is not in general beneficial. The bowels should be kept in a loose state, however, by small doses of rhubarb or castor oil, or some other mild laxative. In' many cases, there is considerable gastric disorder, the appetite being variable and capri- cious—sometimes much depressed, and at others voracious. Where this is the case, emetics may be accounted among our most useful remedies. An aqueous solution of tartar emetic appears to be the best article for this purpose. The emetic may be repeated every third or fourth day, during the active state of the inflammation. To promote the regular performance of the various excretory functions, small doses of calomel with pulvis antimonialis should be given at night, and where the system is very irritable, it will be proper to add a few grains of Dover's powder.* In a few instances I have derived conspicuous benefit from the use of sarsaparilla syrup, with a very minute portion of muriate of mercury, but in many in- stances it failed entirely in doing any good. Where there is con- siderable general irritation, a solution of tartar emetic, given every two or three hours, in doses just sufficient to cause a slight nauseat- ing impression on the stomach, will sometimes prove serviceable. After the alvine discharges have been brought to a healthy state, by the mercurial purgatives, tonics will often afford much benefit. Wardrop recommends the use of the carbonates of soda or potass, either singly, or in combination with small portions of rhubarb and the milder bitter infusions. " In some instances the mineral acids have been very useful, and also the preparations of iron." Quinine, however, is decidedly the most effectual tonic in this species of oph- thalmia, after a proper course of mercurial purgation. In recent and acute cases, the diet should be simple and unirritating; such as liquid farinaceous preparations, or thin animal broths; but in the more chronic variety of the disease, where the system is irritable and feeble, a more nourishing, though plain and digestible diet, must be allowed, in order to support the vigour of the system. Be- sides the general remedies already mentioned, various other articles have been recommended for the treatment of this affection; amongst which the muriate of barytes, and iodine, are the most important Hufeland, in a small monograph on the use of the former of these articles in scrofula, relates some interesting examples of this variety of ophthalmia, which yielded to its powers.! I have employed this remedy in several cases with manifest advantage, and it appears * R.—Calomel gr. iv. Pulv. antimon. ----Doveri aa gr. viii.—M. Divide into four equal parts. X Darstellung der Medicinischen Krafte, der Salzsauren Schwererde. Von Dr. Christ. W. Hufeland, Berlin, 1794. 430 SCROFULOUS OPHTHALMIA. to be worthy of more attention than it has of late years received. The best mode of exhibiting this substance is in solution. A half a drachm of the muriate should be dissolved in an ounce of distilled water; of this solution, from thirty to sixty drops may be given three or four times daily to an adult; and for children, from one to two years old, the dose is from ten to twenty drops. Hufeland says, that the best vehicle for administering this remedy, is a ptisan prepared of lig. guiac, rad. gramin., sarsaparilla, and dulcamara. I have also prescribed the iodine in a few cases, and its use was con- tinued for more than three months, without having in a single in- stance obtained any perceptible advantage from it. Nevertheless, no inconsiderable number of cases have been reported in which this article is alleged to have proved decidedly beneficial, and from its well known influence over strumous glandular enlargements, it is certainly entitled to attention as a remedy in the present affection. Dr. Mackenzie, of Glasgow, speaks in the most favourable terms of the employment of the sulphate of quina in strumous ophthalmia. " After many years experience," he says, " in the treatment of strumous ophthalmia, and a trial of numerous and various internal remedies, I have found none so useful as quina. In most instances its effects have been very remarkable; and, indeed, although I have met with a few cases which appeared to resist its beneficial influence, in most of the little patients to whom I have administered it, it acted like a charm. The dose which I employ is generally one grain thrice a day; and in very young children, half a grain; and in adults two grains."* The Peruvian bark was strongly recommend- ed by Fothergill and Fordycet in the treatment of this affection, but its powers are vastly inferior, in this respect, to the sulphate of quinine. (Mackenzie.) With regard to the employment of collyria, and other local appli- cations, little of permanent advantage is to be derived from them. As palliatives, however, slightly astringent lotions, such as weak solutions of nitrat argent, sulph. zinc, or sulphat. cupri., may be beneficially used where the inflammation and pain is considerable; or a decoction of white poppy heads, " with a considerable quantity of extract of conium dissolved in it, (half an ounce to a quart of the decoction,) applied to the eye five or six times- daily."{ I have found a solution of the nitrate of silver, in the proportion of four grains to the ounce of distilled water, to answer better than any other application of this kind. A few drops of this solution is to be instilled into the eye once or twice daily. Mackenzie speaks well of a collyrium composed of one grain of muriat. hydrarg. dissolved *On the Utility of Sulphate of Quina in Strumous Ophthalmia, with Cases. By Wm. Mackenzie, one of the Surgeons of the Glasgow Eye Infirmary.—Glas- gow Med. Journal, No. i. t Lond. Medical Observations and Inquiries, vol.i. t Med. Chir. Rev. Dec. 1822, p. 538. IRITIS. 431 in eight ounces of water. When the disease is chiefly confined to the tarsi, (ophthalmia tarsi,) benefit may be obtained from the ap- plication of red precipitate ointment, (fifteen grains to an ounce of lard,) to the edges of the lids. Mr. Jeffries observes, that the small pustules which occur on the cornea and conjunctiva, should by no means be opened by art, as they are then apt to degenerate into ulcers, an occurrence which always greatly aggravates the pain, in- flammation, and intolerance of light, and increases the risk of ulti- mate loss of vision from destruction or opacity of the cornea- Blisters very seldom procure any advantage in strumous ophthal- mia. Indeed they often do harm, by the pustular inflammation which is apt to occur around the blistered part, and the consequent additional source of general and local irritation, which is thus created. The insertion of a scton in the back of the neck, is much more useful than vesication in such cases. After the acute character of the disease has subsided, the establishment of such a drain will almost always produce the most favourable effects. In four cases which had resisted for many months the ordinary remedies, the dis- ease gradually disappeared entirely under the influence of a seton in the nape of the neck. 5. Syphilitic and Strumous Iritis. Inflammation of the iris may be produced by various causes, but its occurrence from syphilis is incomparably the most frequent. A vascular zone around the margin of the cornea, attended with cloudiness of the humours; constriction or very limited and slug- gish motion of the pupil; great intolerance of light; obscure vision; a continued deep-seated aching pain in the globe of the eye, fore- head, and circumorbital parts; and the appearance of very fine red lines and specks upon the iris, are the principal phenomena charac- teristic of this variety of ophthalmia. In the progress of the dis- ease, adhesion takes place between the fibres of the iris, " the pupil losing its thin flowing edge, and becoming thick, stunted, and gib- bous." In slight cases, no other appearance of inflammation occurs in the eye, the conjunctiva remaining free from redness. In the more acute instances, however, the sclerotica is usually of a rose-red colour, shading off gradually towards the circumference. The pain, in instances of this kind, is often fitful, and is particularly severe in the evening or early in the morning. The usual sensation, how- ever, (except during these evening or morning exacerbations,) is a feeling of constant painful pressure in the globe of the eye, with more or less of an aching pain in the temples, bone of the cheek, and forehead. In some instances, the pain in the eye is pulsatile," mark- ing every injection of the ophthalmic artery." In very acute and violent cases of iritis, lymph is deposited on the iris, appearing in small yellowish-red elevations on its surface; the pupil usually be- coming angular and misshapen, and sometimes entirely blocked up by a layer of lymph. 432 IRITIS. Mr. Travers divides iritis into primary and secondary. The primary variety is commonly the consequence of syphilis, or of cold while the system is under the influence of mercury, and is distin- guished from the secondary variety by " the more sparing vascularity of the conjunctiva, and the consequent more distinct appearance of the vascular corona round the cornea." It usually comes on rather suddenly; is attended with very severe pain in the orbit and head almost as soon as it commences; and " the vision is more quickly and completely dimmed. In the secondary form the inflammation gradually extends from the contiguous tunics to the iris; the conjunc- tiva is vascular and often nose-red; the cornea much clouded; the pupil retains its natural shape, or is but slightly deformed; the pain is confined in a great measure to the eyeball, and is not often very severe, but the intolerance of light is generally very considerable." (Travers.) When the disease is violent, and continues unchecked in its course, the iris projects forwards, and uniting with the cornea, produces corneal staphyloma. If the inflammation extends to the choroid membrane, retina, and vitreous humour, vision will inevitably be lost Strumous iritis, is most apt to occur in children between the ages of six and eighteen, of a delicate habit, " fair complexion, light hair and blue eyes." The cornea acquires a misty or slightly opaque appearance, with patches of red vessels usually appearing on its edges. A zone of pink vessels is formed around the cornea in various situations. The conjunctiva is but slightly red; and on close inspection the vessels of the sclerotica are found minutely injected, and running in straight lines to the margin of the cornea. Profuse lacrymation occurs, with distressing intolerance of light The iris is nearly inactive, and vision is obscure. "The eyebrow appears to project considerably before the eye; the muscles (if one eye only be affected) become thicker and stronger than those of the opposite side, from their powerful contraction to exclude the light, and give to the countenance a distorted appearance. The pulse is generally quick and irritable; the appetite uncertain; the secretions unhealthy; the skin dry and harsh, but variable in temperature; the heat of the scalp being oppressively great, whilst the extremities are often chilled with cold." Treatment.—Although mercury may be regarded as the princi- pal remedy in this variety of ophthalmic inflammation, yet, general and local depletory measures, free purgation with calomel and jalap, and nauseating doses of antimonials, are essential auxiliaries in the acute stage of the disease. Without mercury, little or nothing can be effected towards arresting the progress of the inflammation. It should be given to the extent of producing ptyalism, except in sub- jects of a debilitated and worn down constitution, where a more moderate mercurial action should be established, and the system supported by a nourishing but unirritating diet. Great care must be had to avoid taking cold while under the mercurial influence in this affection. Belladonna is a highly important remedy in this EXANTHEMATA. 433 species of ophthalmia. Without the use of this narcotic, says Mr. Gutherie, " complete success can rarely be obtained." The extract must be thickly smeared on the eyelids and eyebrows every night. After the inflammation has been considerably reduced, and the into- lerance of light removed, a very small portion of weak precipitate ointment introduced into the eyes twice a week, will often aid materially in completing the cure. Bleeding, cupping, leeching and blistering, are all wholly ineffectual and not unfrequently decidedly injurious. (Gutherie.) Mr. Middlemore, assistant-surgeon of the Birmingham Eye Infirmary, has published a statement which would seem to show that much advantage may be obtained from the use of the spirits of turpentine in this affection.* Mr. Carmichael and Mr. Gutherie, have also given reports illustrative of the usefulness of this remedy. Mr. Middlemore asserts that he gave it with advantage to patients, who from delicacy or constitutional idiosyncrasy were un- able to use mercury to the extent of producing salivation. Where the acute symptoms had been relieved by mercury, the turpentine, given in drachm doses, two or three times daily, manifested a pecu- liarly excellent effect He insists strongly on the early employment of this remedy in inflammation of the choroid and retina. Strumous iritis is extremely obstinate in its duration. In delicate children very small doses of calomel with prepared chalk, may be given every evening, and a grain of quinine twice during the day. The quinine will often do more good in cases of this kind than any other remedy we possess. A seton in the nape of the neck, or a small issue on the arm, will in general contribute considerably to the reduction of the inflammation. Suitable clothing to keep up the regular warmth and action of the skin is an important auxiliary. The patient should also be allowed moderate exercise in the open air; and a simple digestible and nourishing diet is to be enjoined. CHAPTER XVII. OF THE CUTANEOUS PHLEGMASL/E. Exanthemata. The term exanthemata is derived from the Greek word e£av0i»>; effloresco; and is employed to designate those acute contagious affec- tions, in which an efflorescence or eruption appears on the surface of the body. The exanthematous fevers are of a strictly specific character:—that is, each affection of this kind has its specific cause, and cannot, so far as we know, be produced by any other cause or * Medico-Chirurg. Rev. July, 1830. Vol. I.—55 434 VARIOLA. combination of causes. In all of them, fever exists as the primary or essential disease—the eruption being a secondary affection, and the immediate consequence of the specific febrile excitement. Un- less interrupted by constitutional idiosyncrasy, or adventitious influ- ences, each of these diseases has its determinate course, both in relation to the duration of its stages and the succession of its charac- teristic phenomena. They are all communicated by contagion; and they possess the power of destroying the susceptibility of the human organization, to the subsequent morbific influence of their respective contagions, although instances do, occasionally, occur in which this power is, more or less effectively, opposed by the system, and in which, therefore, a second attack is possible. Sect. I.— Variola.—Small-Pox. It is not known at what period the small-pox made its first appear- ance. In the writings of the Greek and Roman physicians, we find nothing which could lead us to believe that they had any particular knowledge of this devastating malady, although we can scarcely doubt that its origin was of a much earlier date.* The Arabian physicians were the first who gave a distinct description of this dis- ease; and it is to the small work of Rhazes, who lived about the be- ginning of the tenth century, that we must look for an account of its early history. It may be collected from the writings of Rhazes and others, that small-pox was probably at first brought from Ethiopia into Arabia, and that it was thence conveyed into the Levant, Spain, and Sicily, by the Saracens, during their hostile irruptions into these countries.! In the eleventh and twelfth centuries, it gained vast * Rhazes, indeed, refers to some expressions in the writings of Galen, which would seem to show that small-pox, though not described, was known by this Roman writer. " As to those physicians," says Rhazes, " who affirm that the most excellent Galen has made no mention of the small-pox, and therefore that he did not know this distemper; surely they have either never read his works at all, or only very cursorily; nay, most of them do not know, whether what he plainly says of it is to be understood of that disease. For Galen, in a certain treatise, says: this** * does good against the small-pox. And in the be- ginning of the fourteenth book of pulses, he says, that the blood is putrefied in an extraordinary degree, and that the inflammation runs so high that it burns the skin; so that small-pox and pestilent carbuncle are bred by it. And in the ninth trea- tise of the book Of the Uses of the Parts, he observes, that the superfluous parts of aliments which are not turned into blood, and remain in the members, putrefy, and in time increasing, do ferment; whence, at last, are generated the pestilential car- buncle, the small-pox, and confluent inflammations. Lastly, in the fourth part of his commentary upon the Timseus of Plato, he says, that the ancients gave the name of x»y,uovfl to every thing which produces redness, as the carbuncle and small-pox."—Treatise on the Small-Pox and Measles. By Abubecker Rhazes, chap. i. Translated by Thomas Stack, M. D., F. R. S. X It would appear, that small-pox was known in Europe as early as the VARIOLA. 435 ground, during the wars waged by the Christian potentates, against the infidel Saracens, for the recovery of the holy land. From that time forwards, its desolating visitations were frequently renewed, in every part of Europe, and there is, perhaps, no single disease, with which the Almighty has thought it good to afflict mankind, which has carried off so many victims to the grave as the present one.* Small-pox is divided into two varieties—namely, the distinct and confluent. In the former, distinct, elevated, distended, and circular pustules are scattered over the surface of the body; in the latter, the pustules are exceedingly numerous, depressed, irregularly circum- scribed, and confluent or coherent. There exists, however, no es- sential difference between these varieties; the division is altogether arbitrary, for in some instances, the pustules are confluent on the face, while on the rest of the body, they are distinct. The time which elapses between the reception of the variolous virus, and the first manifestations of its influence on the system, is said to vary from about seven to twenty days; although by far the most common period of its inception is between the ninth and four- teenth days. During this period of incubation, no obvious symp- toms of indisposition occur—the individual retaining an apparently good state of health. It is stated by some, that the disease is apt to be most violent when this period is of short duration. Course and symptoms of the distinct variety.—The disease commences with a feeling of languor, weariness, aching pains in the back and lower extremities, slight creeping chills, with flushes of heat and pain in the forehead. More or less nausea and vomiting, attended with great thirst, pain in the epigastrium, and some de- gree of soreness in the fauces, speedily ensue. When the fever is completely developed, the skin and face are dry, the tongue white, and generally red at the point, the bowels torpid, and the urine scanty and of a deep red colour. During the first and second days of the fever, slight haemorrhages from the nose are apt to occur; the mind often becomes dejected and confused, and towards the end of the third day, the tongue usually acquires a bright red colour. Shortly before the appearance of the eruption, an unusual tendency to perspiration generally occurs in adults, and frequently much drowsiness, and sometimes coma, supervene at this period. In chil- seventh century. The word variolae occurs repeatedly, in some manuscripts discovered by Dr. Woodville, in the British Museum, and in the Cottonian col- lections, written about the close of the eighth century; and Marius Aventicensis, bishop of Lausanne, in the seventh century, uses these words: Hoc anno variohe cumprqfluvio ventris, Galliam, Italiamque valde affixit.—Gregory* s Practice,vo\. i. p. 197. * It has been estimated, that before the introduction of vaccination, 450,000 individuals died annually of small-pox in Europe.—Richter's Therapie, b. ii. p. 302. 436 VARIOLA. dren the eruption is sometimes preceded by convulsions; but the tendency to free perspiration very rarely occurs in them. In many cases, the hands and feet are cold throughout the whole course of the disease, more especially in very young children. The coldness of the extremities has by some been considered as the most certain diagnostic symptom of the eruptive variolous fever; but the most frequent and characteristic phenomenon of this fever is the pain and soreness to pressure of the epigastrium, and the vomiting. (Philip. Febrile Diseases.) Both in adults and in children, a considerable increase of the febrile symptoms usually takes place a short time be- fore the eruption begins to appear; and in some instances severe cramps in the legs occur at this period. Towards the end of the third, or the beginning of the fourth day from the commencement of the disease, the eruption begins to make its appearance. The pustules appear first on the forehead, and on the parts about the mouth and nose—next on the fore-arms and upon the breast and abdomen—and last of all on the lower extremities; so that in about twenty-four hours the eruption is completed. The eruption consists at first of red points, which by the middle of the second day present small elevations, with inflamed bases, which as yet discharge no serous fluid when punctured, but "the cuticle appears distended by a sort of semi-transparent plastic lymph." Towards the end of the second day, some of these pustules present central depressions; and on the following day this characteristic de- pression becomes conspicuous in nearly all of them. Where there are but few pustules, they often remain elevated and pointed, with but a very slight central depression; but where they are numerous, they assume an umbilicated form, or flattened with a distinct de- pression in the centre. The fluid appears at first in the central points, and is of a limpid and serous character. The pustules con- tinue gradually to increase in size, at the same time that their umbi- licated form becomes more and more conspicuous. About the fourth day they assume a whitish colour, and become surrounded by a pale red areola. When the pustules are very numerous, these areola? run into each other, and give a uniform appearance of redness to the interstitial spaces. The limpid fluid which appears at first in the central part of the pustules, gradually becomes more and more abundant—extends towards the basis of the pustule—and changes from its serous to a purulent character. This change occurs be- tween the fifth and seventh day, and marks the commencement of the stage of Suppuration.—In the distinct variety, the fever which pre- cedes and accompanies the eruption always remits greatly, and frequently disappears entirely, as soon as the eruption is com- pleted. When suppuration commences, however, the febrile symp- toms usually re-appear. As the process of suppuration goes on, the pustules become distended with pus, and, losing the flattened form, acquire a spherical shape. About the eighth day, when the VARIOLA. 437 crop of pustules is pretty numerous, the face begins to swell; the upper eyelids sometimes becoming so tumid and puffy as to close the eyes entirely. Towards the end of the tenth day the swelling of the face begins to subside, but instead of this, con- siderable tumefaction occurs in the hands and feet, and the inter- stitial spaces over the whole body become more or less swollen, tense, and sore. The period of suppuration is almost invariably attended with soreness in the fauces, and where the pustules are numerous, with a copious secretion of viscid saliva. In some in- stances, the increased flow of saliva occurs with the commence- ment of the eruption, but its usual time of occurrence- is after the suppurative stage has supervened. This secretion generally becomes so thick and viscid, that it is spit out with considerable difficulty, and renders swallowing difficult. On examining the mouth and fauces, they are found swollen and.of a bright redness; and from the eustachian tubes becoming closed by the tumefaction, more or less obtuseness of hearing usually occurs. During the lat- ter period of the suppurative stage, a strong and very peculiar odour rises from the patient's body, and this exhalation continues until the process of desiccation is completed. When the tumefac- tion of the face is very considerable, more or less drowsiness or oppression often occurs, and in some instances diarrhoea supervenes towards the completion of the suppurative process. The secondary or suppurative fever varies in violence and duration, according to the copiousness of the eruption, and the activity of the suppura- tion. In mild cases of the distinct variety of the disease, the se- condary fever rarely continues longer than two or three days, and is seldom attended with symptoms of severity. The suppuration, like the appearance of the eruption generally, begins on the face, and lastly on the hands and feet. As the disease advances, the pustules gradually become yellower and more opaque, and arrive at their full state of maturity about the twelfth day.* After the pustules have acquired their perfect state of development, they sometimes remain stationary for several days; but more commonly a brownish spot makes its appearance on the centre of each pustule as soon as the process of suppuration is completed, acquiring at the same time a rougher and deeper yellow aspect. Soon after the occurrence of this change, the pustules begin to shrink, becoming gradually drier, browner, and harder, until the matter is converted into a brown crust. Desiccation always commences on the face, " this part be- ing often covered with scabs, when the pustules on the extremi- ties have scarcely arrived at maturity." When the scabs fall off, * If a mature pustule be opened, which had previously presented a well- marked central depression, a yellowish pus will be found below, presenting a small, white, umbilicated disk, perfectly resembling in form and size, the pus- tule before the pus had altered its shape.—Cazenave. Practical Synopsis of Cu- taneous Diseases, p. 142. 438 VARIOLA. they leave a vividly red surface, which disappears very gradually. In mild cases of distinct small-pox, the suppuration seldom destroys the skin and subcutaneous cellular tissue, and the skin therefore does not become pitted or marked. In the more severe instances of this variety, however, the cicatrices remain with more or less distinctness —becoming more and more visible, as the redness, which remains after the falling off of the scabs, gradually disappears. Confluent smallpox.—The pain in the back and extremities during the eruptive fever, is almost always much more severe in the confluent than in the distinct variety of the disease; and, in general,'all the febrile phenomena are usually more violent in the former than in the latter. The heat of the skin is very great; the thirst exceedingly urgent; the tongue dry, harsh, and sometimes covered with a dark-brown or blackish fur, and the nervous system is often much affected. In the distinct variety, the eruptive fever is almost invariably of the synochus or synocha grade. In the more aggravated instances of confluent small-pox, it often assumes a typhous character; although in the majority of cases, the eruptive fever is highly synochal. The tendency to copious perspiration, often so conspicuous in the distinct small-pox, is rarely observed in the confluent variety; but profuse diarrhoea sometimes occurs just before the appearance of the eruption, and still more commonly dur- ing the suppuration. It has been observed, that the secretion of saliva, commonly so abundant in this affection, is usually very tri- fling, or almost entirely suppressed when diarrhoea attends. In general, the eruption appears at an earlier period in the conflu- ent than in the distinct variety of the disease; and the time of its appearance is altogether much more regular in the former than in the latter. In some instances, the pustules come out as early as the second day, and, occasionally, not until the fourth or fifth day after the commencement of the fever. In many instances of confluent small-pox, a roseolous rash or efflorescence precedes the variolous eruption—a phenomenon which is occasionally observed also in the distinct variety. When the eruption is confluent, the small red papular points which appear at first, run into each other, and form " a large red, tumefied, and somewhat rugose surface." The patient at the same time is very drowsy, and the carotids beat strongly. The pustules of confluent small-pox are commonly irregular in shape, and much less elevated than in the distinct small-pox; and the parts not covered with the eruption are pale and flaccid. The central depression is generally inconspicuous; and about the third day the pustulated surface of the face becomes " covered with a kind of subcuticular whitish pellicle." The tumefaction of the face and hands, as well as the soreness in the fauces and the flow of saliva, are generally very great in the confluent variety. The reverse, how- ever, is occasionally observed; for, in some instances of confluent small-pox, these symptoms are but very slight. When the suppu- ration is completed, a very manifest aggravation of the febrile symp- VARIOLA. 439 toms occurs, constituting what is termed the suppurative or secon- dary fever. The matter in the confluent pustules is of a whitish- brown and sometimes of a dark colour, and of much less consistence than in the mild form of the disease; and in some instances, it ac- quires a corrosive character. About the eighth or ninth day of the eruption, the matter begins to escape from the pustules, and hardens on the surface into extensive brown crusts, which fall off at periods varying from the fifth to the fifteenth day from their formation, and are succeeded by desquamations which finally leave deep marks or pits, which are often so united as to form "seams that traverse the face in all directions." Both in the distinct and confluent varieties of the disease, great itching attends the period of desiccation. The eruption of small-pox is not confined to the external surface of the body. The pustules occur also on the mucous membrane of the mouth, larynx, and trachea, and on the tongue—giving rise to more or less copious ptyalism, hoarseness, painful swallowing, diffi- culty of breathing, cough, viscid expectoration, and perhaps diarrhoea. The disease is sometimes, from the commencement, of a highly inflammatory character. It begins with strong chills, succeeded by intense febrile heat; a frequent, full, and hard pulse; high-coloured and scanty urine; flushed countenance; sometimes delirium; and, in children, often convulsions. Internal inflammations, particularly of the brain or lungs, are apt to supervene in cases of this kind. When the former organ becomes the seat of the inflammation, vio- lent delirium, coma, convulsions, or apoplexy ensue. Thoracic in- flammation is indicated by the occurrence of pneumonia, pleuritis, or effusion into the Jungs. The eyes, too, are apt to become inflamed, and the parts not covered with pustules are vividly red and much tumefied. In some instances the attending fever, even in the distinct variety of the disease, is typhoid. The chilly stage is unusually protracted; the pulse remains small, weak, and frequent, and the patient com- plains of much muscular prostration. Various symptoms of nervous disturbance are apt to occur—such as vertigo, faintness, twitching of the tendons, and even convulsions. The urine is colourless and the face pale and sunken. The pustules come out slowly and irregu- larly, appearing simultaneously on every part of the body, and some- times first on the extremities, and are often congregated in irregular clusters. The eruption sometimes disappears on some parts without passing into the pustular state; and slight causes, such as cold or mental agitation, may even occasion the whole eruption to recede; in which case, convulsions, or apoplexy, or fatal congestion and effu- sion into the lungs are apt to supervene. Suppuration goes on slowly and often imperfectly, the pustules becoming filled with a thin watery pus. The intermediate skin is seldom much tumefied, and remains pale. In the advanced period of the disease, the swel- ling of the face and extremities sometimes subsides suddenly, and the patient dies apoplectic. Desiccation generally commences seve- 440 VARIOLA. ral days earlier than in the ordinary course of the disease; and at this period the fever is apt to become much aggravated.* The disease sometimes manifests a highly malignant or putrid character—more especially the confluent variety. The heat is acrid (calor mordax;) the perspiration clammy and offensive; watery diarrhoea often occurs; the face is bloated and red; the eyes watery and inflamed; the appearance of the eruption and its progress are irregular. The pustules commonly acquire a dark or livid hue; are surrounded with brown or almost black margins; and become filled with a bloody serum^instead of pus. Colliquative haemorrhages, particularly from the nose, are common. Desiccation leaves very dark or black crusts, beneath which phagedenic ulcerations are not unfrequently formed.! When the small-pox attacks females in the state of pregnancy, it frequently gives rise to abortion, more especially during the early periods of utero-gestation. Such are the usual course and phenomena of the distinct and con- fluent varieties of small-pox. It is subject, however, to considerable irregularity, both in relation to its general progress and the charac- ter of its particular symptoms. But the most remarkable variety of anomalous small-pox is that which has been termed the chrystalline, and in which, instead of pustules containing purulent matter, the eruption consists of phlyctenae, or vesicles filled with a colourless transparent serum. The phlyctenae soon become pale, and although not confluent, are never surrounded by inflamed margins. This variety of the disease is of a most dangerous character. In many instances, no tumefaction of the face or hands occurs, a circumstance which is particularly indicative of great violence and danger; " for, instead of these swellings, the inflammation generally seizes on the brain." The secondary fever in this variety of the disease usually assumes an evident typhoid character. The sequelae of small-pox are very various, and often extremely distressing. The disease may give rise to slow and wasting fever, dropsy, chronic cutaneous affections, phagedenic ulcerations, necro- sis, chronic ophthalmia, rheumatic pains, deafness, paralysis, struma, phthisis pulmonalis, mania, epilepsy, opacity of the cornea, staphy- loma, dropsy of the eye, and cataract. The small pox is sometimes remarkably modified by the influence of the contagion of measles. Sydenham observes, that in 1670-71-72, the small-pox and measles prevailed at the same time in London, and that, during this period, the variolous affection assumed an extremely irregular and violent character. The eruption, at first, resembled measles or erysipelas; in its progress, small vesicles filled with a colourless fluid appeared among the variolous pustules. The scabs formed on the pustules resembled concreted blood, and at last became almost black. * Richter's Specielle Therapie, b. ii. p. 297. f Ibid, p. 299. VARIOLA. 441 The influence of measles on the progress of small-pox, when the two diseases meet in the same individual, is equally remarkable. It has been frequently noticed, that the supervention of measles dur- ing the early periods of small-pox, causes this latter disease to remain nearly stationary until the morbilious affection has run its course, when the small-pox resume their progress and proceed to their regu- lar termination. Thus, if on the second day of the small-pox erup- tion, the measles make their appearance, the small-pox will remain stationary until the measles have gone off, after which, the variolous disease will resume its dominion and go on iiythe^iisual way. Post mortem appearances.—The morbid^irppearances on dissec- tion vary, of course, considerably, according to the stage of the dis- ease during which death takes place, the violence of the particular symptoms, and the accidental affections with which it may be com- plicated. Sanguineous congestions in the brain and lungs are gene- rally strongly manifested. Pustules are not unfrequently found in the larynx, trachea, and bronchia, as far as the third division. In the pharynx too, the variolous pustules are sometimes pretty nume- rous, but they are very rarely found in the oesophagus. Traces of inflammation to a greater or less extent are almost invariably de- tected in the mucous membrane of the alimentary canal, and pustules of a variolous character are sometimes met with in the lower portion of the rectum. It is observed by Cazenave and Schedel, that they had never in any of their dissections found the pustules on the mu- cous membranes distended with- pus. It does not appear from the observations of those who have paid particular attention to the post mortem appearances in this disease, that the variolous pustules are ever found on the viscera or in the closed cavities of the body. Some late writers assert, that the internal surface of the aorta almost constantly presents a vividly red appearance, but the frequency of this appearance is denied by Cazenave and Schedel. The pustules on the skin, when anatomically examined before they are distended with pus, or before they have lost their umbilical form, present the following appearances: 1st. "The cuticle preserves its natural thickness, and is easily detached, leaving exposed a whitish and smooth surface, elevated at the edges and depressed in the centre. 2d. " A small umbilicated disk of various thickness, formed by a whitish substance, having a certain consistency, and which appears to be a real exudation from the inflamed dermis. This substance occupies the place of the mucous coat, and at first appears to be con- tinuous with the layer which is immediately under the epidermis, but afterwards is easily separated from it. This small body adheres to the dermis by its centre, where it is also much thinner, and often tears when it is attempted to be raised." If, when the cuticle is elevated by the pus, the pustule be examined with care, it will be found that the bottom of the pustule still presents the same umbili- Vol. 1.—56 442 VARIOLA. cated form that it possessed before the cuticle was raised and distend- ed by the purulent fluid. 3d. " Finally, below this small disk, the dermis is of a red colour, and sometimes covered with purulent fluid."* The true seat of the small-pox pustule appears to be in the reticu- lar tissue which lies between the cutis vera and the cuticle. In its early stage, the pustule, when examined with a lens, exhibits a cel- lular structure, and from the sixth to the ninth day, a thin cir- cular slough of the true skin may be observed at the bottom, which, on being finally cast oJLgives rise to a depression or pit in the skin. Cause.—Small-poxTltsp far as we know, can arise only from one cause—namely, a peculiar contagious substance, which occurs both under the form of a palpable matter and of an imperceptible efflu- vium, but of whose intimate nature and origin we are entirely igno- rant. Observation has made us acquainted, however, with its obvi- ous relations as a morbific agent, and with some of the influences, both vital and extraneous, which tend to modify its operation on the human system. It does not appear that age or sex exerts an)' con- trolling power over this contagion, and we know that even the foe- tus in the womb is not exempt from its morbific effects. Nor does climate or season, so far as the sensible atmospheric conditions are concerned, appear to exercise any influence either in retarding or favouring its dissemination. One of the most remarkable and mys- terious phenomena of this, as well as of other epidemic contagious diseases, is its recurrence at distant intervals in an epidemic form, depending, no doubt, on certain occult atmospheric constitutions peculiarly favourable to the operation of the variolous contagion. The disease occurs, indeed, also sporadically; but during certain pe- riods, its contagion may thus here and there manifest its presence, without passing from individual to individual, and be speedily extin- guished, like sparks thrown among incombustible materials. What these atmospheric conditions consist in, if in truth the phenomenon in question depend on atmospheric modifications, we know not. Whatever may be the general cause to which these influences be- long, it is probable, that its effects are exerted rather upon the hu- man constitution, by which its susceptibility to the operation of the variolous virus is either increased or diminished, than in modifying the activity of the contagious principle itself. The susceptibility to the operation of the small-pox contagion varies much in different individuals, not only in relation to the liability of becoming affected by it, but also to the degree of vio- lence which the disease, arising from the same source of conta- gion, assumes. Thus, some persons, (though indeed very few) ap- pear to be naturally insusceptible of the disease; others are affected, even by inoculation, with great difficulty; and among a number of individuals exposed to the same contagion, the disease will assume * Cazenave, loc. cit. VARIOLA. 443 a confluent form in some; in others it will be severe but distinct; in a third, mild and distinct; and in others, again, it will be very mild, and scarcely attended with any eruption. These diversities in the effects of the contagion must be ascribed to original idiosyn- crasy, temperament, and to accidental modifications or conditions of the organization. One thing is well ascertained in relation to this point—namely, that whatever tends to reduce the general vigour and phlogistic habit of the system, tends also to lessen the violence of the variolous affection; and it is to this circumstance that we owe all the peculiar advantages which are ^rjvedjfrom inoculation. The variolous contagion possesses the power of destroying the sus- ceptibility of the system to its subsequent operation, so that a se- cond attack of perfect small-pox in the same individual, though an occasional, is far from being a common occurrence. Instances of a second, and even a greater number of attacks in the same person, have indeed been frequently noticed; and when we take into ac- count those incomplete cases which are termed varioloid, secondary attacks of the disease may be considered as very frequent. Prognosis.—Small-pox varies exceedingly in relation to its vio- lence and the degree of its dangerousness. The distinct and simple form is by no means a dangerous affection; whilst the confluent vari- ety is always attended with great hazard to life. In the more violent cases of the disease, death sometimes takes place as early as the fifth or sixth day; but the greatest fatality occurs during the stages of sup- puration and desiccation. The prognosis depends chiefly on the quantity of the eruption; the character of the pustules; the nature of the attending fever; and on the accidental morbid complications. However regular the progress of the disease may be, the danger is always great when the pustules are very numerous, more especially when they are confluent. It would seem from estimates that have been made in relation to the mortality from small-pox, that nearly three out of five instances die in the confluent variety. The check which a very copious crop of pustules must neces- sarily give to the cutaneous exhalation, and more especially the great irritation caused by so extensive a surface of suppuration, and perhaps the absorption of the pus itself, are the principal causes of the fatal character of the confluent variety of the disease. In re- lation to the form and appearance of the pustules, it may be ob- served, that the more elevated they are, the more distinctly they are surrounded with red areolae; and the more regularly they be- come filled with a thick yellowish pus, the more favourable is the prognosis. When, on the contrary, the pustules are flat or de- pressed, coherent, or congregated in clusters, warty, empty, or filled with a colourless watery fluid, it is a very unfavourable sign. It is a still worse indication when the pustules become filled with blood.'* With regard to the character of the attending fever, the * Richter, loc. cit. p. 330. 444 VARIOLA. more decidedly phlogistic or typhoid it is, the more danger is there to be apprehended. A moderately active state of fever is favourable, but a tendency to a low grade of reaction is the re- verse. Richter observes, that when the disease is complicated with prominent catarrhal symptoms; or with difficult dentition; or in- testinal irritation from worms; much danger may be apprehen- ded. In general, the prognosis is unfavourable when the disease occurs in old persons of enfeebled constitutions; in plethoric, robust, and vigorous adults; and in very young infants. Pregnancy, or the puerperal conditional so tends to increase the dangerousness of the disease. It rrSsJ^en observed, that the period of life most favourable to a mild and regular course of the disease, is between the third and the tenth year of age. The age of puberty in females, is said to be a particularly dangerous period in relation to this com- plaint* Convulsions just before the appearance of the eruption, are rarely attended with any serious consequences; but when they occur during the period of suppuration, the danger is always ex- tremely great Suppression of the urine, or a very frequent desire to void it, is said to be a very unfavourable sign, when it occurs during the sup- purative stage. It is also a particularly dangerous sign, when the pustules, about the sixth or seventh day of the stage of suppuration, become collapsed, and the swelling of the face suddenly subsides, at the same time that the areolae disappear, and the intermediate skin becomes pale and flaccid. The sudden recession of the eruption, soon after its appearance, is always very dangerous. Of course, the supervention of visceral inflammation, or of sudden violent conges- tions of blood in the brain and lungs, are occurrences of the most alarming character. Treatment.—There is, perhaps, no disease in which false theory has led to such fatal consequences in practice, as small-pox. During the general prevalence of the doctrine of morbid humours, it was supposed that the variolous matter was formed by a species of fer- mentation in the blood, and that the more perfectly this matter was separated and cast upon the skin, the greater would be the chance of recovery. Great efforts were accordingly made to assist nature in establishing as copious a crop of pustules as possible; and under this fatal delusion, all kinds of heating medicines and external warmth were diligently applied. When we reflect on the inevitable result of this practice, so long and so universally pursued, we see in it a frightful drawback on the amount of benefit conferred by the heal- ing art in relation to this disease, although this amount must be re- garded as immense, from the introduction of inoculation, and espe- cially of vaccination. Among the moderns, Sydenham appears to have been the first who saw the fatal tendency of the heating or exciting plan of treatment in small-pox. He revived the cooling or * Richter, loc. cit. p. 330. VARIOLA. 445 antiphlogistic treatment of the Arabian physicians,* a mode of man- agement which is now universallydcknowledged as the only prac- tice capable of mitigating the violence and dangerous character of the malady. Instead, therefore, of supporting the excitement during the erup- tive fever, that the eruption may be copious, we must endeavour to moderate the febrile reaction, that the pustules may be as few as possible. By an early attention to the fulfilment of this object, the disease will often pursue a mild and simple course, whilst under the employment of exciting remedies, it wouifcin all probability, have * The general plan of treatment laid down by Rhazes, differs in no essential point from that which was recommended by Sydenham. For the purpose of di- minishing the violence of the disease in those who are exposed to the small-. pox contagion, Rhazes advises, that "a vein be opened in those who are four- teen years old. To those who are younger, cupping-glasses must be applied, and their lodgings should be kept cool." The diet, he says, must "consist of yellow lentils, tarts of unripe fruits;" and their drink " should be water cooled with snow, or "clear cold spring water, with which also their chamber may be sprinkled." They must frequently eat "acid pomegranates, and the inspissated juices of acid and astringent fruits." The patient must "go into cold water and swim in it, about noon. He must abstain from wine, and meats made by a mix- ture of flesh, onions, oil, butter, and cheese;" as well as from " mutton, beef, shell-fish, and high-seasoned things, and hot seeds; but, if his temperament be hot and dry, and apt to be inflamed, he must eat cooling and moist garden-herbs, purslain, mallows, beets, gourds, cucumbers, sorrel, and small pompions. All acid things are proper to cool the blood and check the ebullition, especially the water called Al-rdib, that is, the sour, bitter water, which swims upon butter- milk, exposed to the sun. When the variolous fever has supervened, care must be taken not to refrigerate too much, so as not to extinguish preternatural and natural heat together." Nevertheless, when, during the fever, " you observe great pain in the back, redness of the face and eyes, a violent headach, a full pulse, with a straitness of breath, a red and turbid urine, and such a heat of the body as a man feels who has been for some time in a hot bath; there is then all the reason in the world to take away blood, even till the patient faints away. But, if the symptoms do not run very high, although they are manifest, draw blood but sparingly. In order more perfectly to extinguish the feverish heat, let the patient drink water, made cold in snow, very plentifully; so that he may feel the coldness of it in his bowels. If still the heat return, and the belly be full of water, make him vomit it up, and then give it him again." During the eruption and suppuration, the patient " must be kept in a room not very cold; he should drink frequently, a little at a time, of cold water." "As to the furnaces and baths, they are both destructive, at this time, by overheating and weakening." When the erjiption goes on slowly and with difficulty, the cooling and extinguishing remedies " must be absolutely forborn." The drinks " must be warm."(a) (a) Rhazes, loc. cit. 446 VARIOLA. assumed a confluent and highly dangerous character. It is upon the power which an antiphlogistic treatment exerts in moderating the violence of the disease, or of rendering the eruption scanty, that all the advantages of inoculation depend. When an individual.is inocu- lated, the phlogistic state or tendency of his system is diminished by purgatives, simple and cooling diet, and, in plethoric subjects, by bleeding; in consequence of which, a less copious crop of pustules ensues, and the disease, in general, pursues a proportionately milder course. Sydenham resorted^fcthe lancet as the principal means for mode- rating the febrile excitBnent There can be no doubt, indeed, that bleeding must often prove very beneficial; but, it seems to be ad- mitted on all hands, that it cannot be employed with great freedom, without considerable, risk of mischief, unless the reaction be very violent, or the general phlogistic condition great " It is an obser- vation universally applicable," says Dr. Philip, " that blood-letting is only to be recommended when the effects expected from it cannot be procured by other antiphlogistic remedies." Cathartics of the milder kind are always highly useful during the eruptive fever, in cases requiring a reduction of the general excite- ment. Very active purging—more especially in mild'cases, or when the appearance of the eruption is at hand—is improper, as it may readily interfere with the regular progress of the eruption, by the centripetal direction it tends to give to the circulation. Through- out the whole course of the disease, however, mild laxatives may be beneficially employed. These observations have.a reference to the distinct variety of the disease; for in the more violent or confluent form, we may derive advantage from active purging during the eruptive fever. Calomel is one of the best purgatives in small-pox. Its operation is sufficiently mild,- and it would seem, that it possesses peculiar powers in moderating the violence of the disease. (Mead, Boerhaave.) The neutral purgative salts, also answer well during the eruptive fever. Some have recommended emetics in the commencement of the disease; and where there are signs of vitiated secretions in the sto- mach, they may no doubt be useful when early administered. When given about the seventh day of the confluent variety, they are said to have no inconsiderable influence in moderating the secondary fever; but in general, they are most useful when given in the onset of the complaint. (Philip.) Diaphoretics of the refrigerant kind will assist in moderating the eruptive fever. Nitre, with small doses of tart, antimony; the saline effervescing draught; spiritus mindereri; sweet spirits of nitre with vin. antim., a solution of muriate of ammonia, &c. may be used for this purpose. . But the most grateful, and at the same time the most safe and va- luable means for moderating the eruptive fever, and thereby lessen- ing the number of pustules, is the cooling regimen. The free ad- VARIOLA. 447 mission of cool air into the sick chamber during the eruptive fever, is in all cases, whether the disease be of the distinct or the confluent variety, of great importance; and it seldom indeed fails to mitigate the symptoms, in a greater or less degree, throughout the whole course of the disease. The patient should lie on a mattress, with light and cool coverings; and his drinks should consist of cool, aci- dulated beverages. The temperature of the sick chamber must of course be regulated according to the season of the year, and the de- gree of febrile excitement present. In warm weather, the external air must be more freely admitted than in cold seasons; and more reduction of temperature is necessary wh^n -the excitement runs high, than where it is of a low or feeble kind. There is but one form of small-pox in which the cooling regimen is said to be objec- tionable, na-mely, the crystalline. The air surrounding the patient ought to be kept uniformly at a temperature just low enough to give the sensation of moderate coolness. If the fever continues after the eruption is completed in the distinct variety of the disease, it will still be proper 'to go on with the coojing treatment, together with mild laxatives, diaphoretics, and antimonials. It has already been stated that in the confluent variety of the dis- ease, the fever often assumes a low typhoid character; and in in- stances of this kind, the diet, instead of being cooling and diluent, should be more or less exciting and supporting. Where the gene- ral excitement is low and sinking, it will even-be necessary to resort to the more active stimulating and tonic remedies, such as wine, carbonate of ammonia, camphor, musk, &c. Camphor is a particu- larly valuable article in such cases where delirium attends. The Peruvian bark has also been very favourably mentioned as a remedy in such cases; and where the process of suppuration goes on tardily and imperfectly from want of general energy, large doses of this article, or of quinine, are indeed highly useful. Under similar cir- cumstances—that is, where the pustules are slow in filling up, or the fluid in them remains watery,—opium in combination with cam- phor has been found a very useful remed)'. (Philip.) When during the progress of the disease, internal visceral inflam- mations supervene, local abstractions of blood from the external region of the affected part, blisters, scarifications, and, where the general arterial action is not too low, bleeding from the arm, must be resorted to. In instances attended with cerebral inflammation, much benefit may often be derived from flannel wrung out of hot water applied to the feet, at the same time that pounded ice is ap- plied to the top of the head. The occurrence of profuse diarrhoea during the secondary fever of confluent small-pqx, must be counte- racted by astringent and absorbent remedies. From eight to ten grains of prepared chalk, with a grain of pulv. ipecac, compositus, will generally answer our purpose in such cases. It is not, however, proper to arrest the discharge wholly in such cases. It should be moderated only. When violent and continued vomiting occur, we 448 VACCINA. may resort to opium and camphor. One grain of the former with two of the latter may be given every hour or two, according to the violence of the symptoms. To prevent the pustules from affecting the globe of the eye, and injuring the sight, pieces of folded linen wet with cold water should be kept applied to the eyes during the eruptive fever. The appli- cation of camphorated spirits has been used for this purpose; but cold water is more agreeable, and also most effectual in this respect. The use of lunar caustic, as a local application to the pustules, has of late been recommended and successfully practised in France, for the purpose of lessening the number of pustules, and by so doing, rendering the disease milder and less dangerous. In 1825, M. Vel- peau read a memoir before the Royal Academy of Medicine, of Paris, tending to prove, that if the pustules of small-pox are caute- rized during the first two days with lunar caustic, their progress will be arrested. This practice was fully tested some time after, by Dr. Meyreux. According to his report, it appears, that if the variolous pustules are opened with a lanjcet, and touched with a pointed piece of lunar caustic, on the first or second day of their appearance, they will be wholly destroyed, and leave no marks; but on the third day it will be quite useless. When soon after the eruption has appeared, it is again driven in, (an occurrence which may proceed from the sudden application of cold and damp air, or from the supervention of excessive purging or vomiting, or other rapidly exhausting circumstances, such as sudden terror, or grief, or syncope, or excessive abstractions of blood,) im- mediate recourse should be had to means that have a tendency to determine the circulation to the surface, such as camphor and opium, carbonate of ammonia, warm bathing, sinapisms to the extremities, and gentle frictions with dry flannel or the flesh-brush. Where the retrocession arises from cold, an emetic, with stimulating frictions, will often promptly recall the eruption to the surface. Sect. II.— Vaccina.—Cow-Pox. Long before the time of Jenner, it was known in some of the dairy counties of England, that cows are subject to a pustular dis- ease, which, when communicated to the hands of milkers, renders them insusceptible of the variolous infection. Although this fact was noticed, and even artificial inoculation with the vaccine matter successfully practised in an instance which was formally communi- cated to Sir George Baker; yet the whole credit of introducing the cow-pox into general notice is due to Dr. Jenner. The benefits which this important discovery has conferred upon mankind are incalcula- ble; and it is not a little consoling to reflect, that as the hand of Providence has in this instance provided a salutary check to one of the most fatal maladies with which man has been afflicted, there may yet be brought to light, at some future period, other antidotal or VACCINA. 449 prophylactic powers against the ravages of diseases, which in the present state of our knowledge, are in a great degree uncontrollable. Although Jenner had made successful experiments with the vac- cine matter as early as the year 1796, he did not publish the result of his investigations until two years after. From that period on, the knowledge of the benefits of vaccination spread rapidly throughout Europe and this country; and there is now no civilized people on earth, amongst whom its blessings have not been largely experienced and gratefully acknowledged. Various opinions have been expressed ^th regard to the origin of the vaccine disease. Dr. Jenner, at firs^ascribed its source to the grease of horses; and this opinion is indeed supported by very strong, though perhaps not absolutely satisfactory evidence. It is asserted by some, for instance, that a pustular disease, in every re- spect similar to the vaccine infection, may be produced both in the human subject and in cows by inoculation with the matter of grease. Friese, Loy, and particularly Sacco,* affirm that they have succeeded fully with this experiment; and Mr. Ring states, that " he succeeded in producing the disease artificially in a cow by removing a scab from the teat, and applying the recent blackish matter of grease to the surface of the sore." The same author has published a letter from Mr. Rankin, relating a case of pustular disease strongly re- sembling the casual cow-pox, accidentally produced on the face and hands of a farmer, by the fluid oozing from the heels of a horse la- bouring under grease. It appears, moreover, that persons who have been affected with the pustular disease produced by the matter of grease, are insusceptible of the contagion of small-pox. Dr. Jenner relates a case of this kind. Sheep, also, are subject to a pustular af- fection about the head and mouth, which is said to be communica- ble to the human subject, in whom it produces a disease very simi- lar to that which is caused by the matter of grease, and which it is asserted by Sacco and Richter, renders the human system incapable of receiving the variolous infection. It has also been supposed, that the vaccine disease is essentially the same as small-pox, and that these two affections derive their origin from the same ultimate source. It is conjectured that the small-pox was at first derived from the cow-pox or grease of horses in Arabia, and that in the course of time it gradually degenerated, by passing successfully through the hu- man system, until it acquired the known virulence and activity of variolous contagion. In confirmation of this supposition, it is asserted that cases have occurred where the variolous matter, inserted into the udder of cows, produced in them a pustular affection not to be distinguished from the cow-pox. Richter makes this observation on the authority of Gassner.t It is also asserted by Dr. Lisa, that * Neue Entdecknngen uber die Kuhpocken, die Mauke u. Schaafpocken. Translated from the Italian, by W. Sprengel, 1813. + Specielle Therapie. Vol. I.—57 450 VACCINA. sheep are effectually protected from the disease called sheep-pox, by inoculating them with variolous matter. Sheep inoculated in this way, are said to become affected with but one pustule at the point where the variolous matter is inserted.* The original identity pf variolous and vaccine matter has recently been incontestibly demon- strated, if we are to place any reliance on the correctness and vera- city of Dr. Ozamann, of Lyons. In a paper which was read at the French Academy of Medicine in July 1S30, it is asserted, on the authority of Dr. Ozamann, that the matter of small-pox, if mixed with fresh cow's mill;, produces when inserted by inoculation an eruption similar, in all;respects, to that of the vaccine virus, and that inoculation with this matter will answer fully for the production of the usual vaccine disease.! Symptoms and progress of the disease.—When the vaccine dis- ease is communicated to the human subject, it proceeds through its course in the following manner. Towards the close of the second day after the insertion of the virus, a small point of inflammation may, usually, be seen where the puncture was made. On the third day this point is more distinct; on the fourth, it generally assumes the character of a small pimple encircled by a very faint and narrow inflamed basis or areola. This pimple now gradually enlarges, and on the fifth day begins to assume a perfectly regular and circum- scribed form, with a flattened surface, and a small depression at the centre, somewhat darker than the rest of its surface—an appearance which it preserves throughout its whole subsequent course. About this period also, the vaccine pock changes from the pimple to a ve- sicle, containing a limpid fluid. From the fifth to the ninth day, the pock continues to enlarge in its circumference, but not perceptibly in elevation, so that its flattened appearance becomes more and more conspicuous. About the ninth day the pustule is at its full state of maturity, and it is at this period that the constitutional symptoms. (if any occur) begin to show themselves. In some instances the glands of the axilla become painful and swelled, and a state of gene- ral languor and drowsiness, with slight creeping chills and alternat- ing flushes of heat occur. Frequently, however, no constitutional symptoms whatever supervene. About the eighth day the slight circle of inflammation which surrounds the pustule in its early pe- riod begins to increase, until by the tenth or eleventh day it forms a broad and beautiful areola round the pock. By the eleventh day, the centre of the pustule, which is slightly depressed, begins to as- sume a darker appearance, and this darkness gradually extends to- wards the circumference, so that by the fourteenth day the surface of the pustule is converted into a brown scab. This scab becomes darker and darker, until it acquires a deep mahogany appearance. In a few days more, the scab begins to separate at the circumference— * Mediz. Chirnrg. Zeit. 1809. No. xliii. Salzburg. f Rev. Encyclop. Aout. 1830. VACCINA. 451 still, however,retaining its attachment at the centre; and eventuaUy falls off, generally between the third and fourth week from the time of vaccination, leaving a slight depression in the skin The areola is usually most perfect about the seventh day after the commencement of the pustule,or on the eleventh day after the vaccina- tion, and is attended with some degree of tumefaction and hardness The foregoing description answers to the regu ar progress of the disease; but various deviations are occasionally observed in relation to some ef the particulars j>t described. -In some cases for in- stance, the pustule furnishes well-formed vjcc.ne lymph as early as the fourth day of its progress. Much diversity occurs also with re- gard to the time when the disease first manifests itself after the vac- cination is practised; for in some instances, eight or nine days, and occasionally even a longer period, intervenes between the vaccina- tion and the commencement of the pustule. It often happens, that on the day succeeding the vaccination, con- siderable inflammation and elevation of the cuticle takes place at the point where the puncture was made. When this is observed we may confidently predict the failure of the operation. Tins inflam- mation continues for a day or two, and then subsides quickly with- out leaving any local affection. . It seldom happens that more than the pustule which rises at the point of vaccination appears on the body. Occasionally one or more smaller pustules appear in the vicinity of the primary one; and in- stances have occurred, in which a pretty numerous crop of pustules came out on different parts of the body. In the report of the cen- tral vaccine committee of France, for 181S-19, it is stated that no inconsiderable number of cases occurred, in which a spontaneous eruption of many pustules appeared after vaccination, and that the matter taken from these pustules produced the disease as perfectly in others, as that taken from the primary pustules. It is a curious and interesting fact, that the vaccine disease occa- sionally counteracts or removes other affections of a chronic charac- ter—particularly chronic cutaneous diseases. In the report of the French committee just referred to, it is stated that " thirteen medi- cal men have seen examples of vaccination proving the means of curing other eruptions, more especially the crustea lactea; and fully authenticated instances are recorded of the removal of scrofu- lous swellings, ophthalmia, and hooping-cough, by vaccination. Of the power of the vaccine disease to moderate and abridge the course of hooping-cough, I have myself witnessed several examples. Another very important circumstance in relation to the mutual influence of the vaccine disease and other cutaneous affections, is the well-established fact, that important varieties and modifications of the vaccine pustule are caused by herpetic and other eruptive states ol the skin. Dr. Jenner, in a paper published in the sixty-sixth num- ber of the London Medical and Physical Journal, points out the fact, that a single serous blotch existing upon the skin during the pro- 452 VACCINA. gress of the vaccine vesicle, may occasion such irregularity and de- viation from the genuine course and character of the disease, that it cannot be depended on as a prophylactic against the variolous infec- tion. In a letter addressed by him to the medical profession gene- rally, dated April, 1821, he observes: " I have found abrasions of the cuticle to produce the same effect—such, for example, as we find in the nurseries of the opulent, as well as in the cottages of the poor, behind the ears and upon many other parts where the cuticle is ten- der. We find irregularity in the vaccine vesicle, if the skin is beset with herpetic blotches, or even simple serous oozings from an abra- ded cuticle. A speck behind the ear, which might be covered with a split pea, is capable of disordering the progress of the vaccine vesicle." Diagnosis.—An attention to the following circumstances, will enable us to distinguish the genuine from the spurious disease: 1. In the genuine disease, little or no inflammation, except what occasionally arises from the mere puncture of the lancet, can be per- ceived until about the third day, and sometimes not until several days later. In the spurious affection, on the contrary, considerable inflammation and elevation of the skin at the punctured point, gene- rally appears as early as the second day. 2. In genuine vaccina, the small point of inflammation which ap- pears three or more days after the matter is inserted, increases gra- dually until about the seventh day after its first appearance,fat which time it is in its full state of perfection. In the spurious disease, the pustule arrives at maturity and finishes its course in a much shorter time. By the third or fifth day from the first appearance of the inflammation, scabbing commences. 3. In genuine cow-pox, a beautiful circular and circumscribed areola almost always surrounds the pustule, and this areolar efflo- rescence is usually in its perfect state about the seventh or eighth day. In spurious affections of this kind, an irregular superficial inflammation occurs on the first "or second day after the appearance of the pustule; and the pustule itself appears more like a common festering sore produced by a thorn, than a pustule excited by the vaccine virus. 4. The genuine pustule is perfectly circumscribed, with a flat- tened surface and a slightly depressed centre, and contains a colour- less transparent fluid. The spurious pock is more elevated, not de- pressed in the centre, is irregular or angulated in its circumference, and contains an opaque purulent matter. According to Dr. Willan, the vaccine vesicle is to be regarded as imperfect when—1, though perfect in its form and appearances, it is without an areola on the ninth or tenth day. 2, when the vesi- cle is very small, pearl-coloured, flattened, with a hard, inflamed, and slightly elevated base, a dark-red areola, and without a rounded or prominent margin. 3, when the vesicle is small, pointed, with a very extensive pale-red areola. The spurious disease may be pro- duced—1, by the genuine vaccine virus .acting on a system affected VACCINA. it3J • with some cutaneous disease; 2, by vaccinating with matter which has undergone more or less decomposition by long keeping; 3, by vaccinating with matter taken from a spurious pustule; and 4, by the genuine vaccine matter being controlled, or in some way di- verted from its regular operation by idiosyncrasy, or a depraved condition of the system. Some difference of opinion has been expressed with regard to the period at which the vaccine lymph should betaken from the pustule, in order to obtain it in its most perfect and active state. Dr. Jen- ner advises that the virus be taken a short time before the areola is completely formed, and consequently soott after the lymph is se- creted in the pustule, or about the sixth or seventh day. To obtain the virus, the edges of the pustule must be gently punctured with a lancet.in several parts. The lymph will then ooze out, and may be collected and preserved between two glasses. Of late years, however, it has been more customary to vaccinate from the scab. For this purpose, no scab except from the most perfect pustule should be taken. It should be smooth, of a dark-brawn or maho- gany colour, and rather brittle than tenacious in its texture. When used, the margin, which is of a lighter colour, should be removed with a knife, and a portion of the remaining dark, hard, internal part reduced to powder on a glass, and moistened or dissolved with a small portion of cold water. In taking either matter or the scab for vaccination, it is of great consequence to be well assured that the per- son from whom it is taken was healthy, and particularly that he was not affected with any cutaneous disorder. A want of due care on this point, may give rise to extremely unpleasant and even danger- ous consequences. I have several times known obstinate and alarm- ing cutaneous affections communicated to children by vaccinating with matter taken from unhealthy subjects. It is a common belief among persons out of the profession, that the vaccine disease is apt to give rise to disagreeable eruptive affections, and such occurrences are in fact not very unfrequent Accidents of this kind probably depend most commonly on the matter having been taken from per- sons affected with some cutaneous disorder, or with a general ca- chetic or depraved habit of body. It seems, nevertheless, that the vaccine disease, communicated by the purest lymph, will occasion- ally excite pustular and other external inflammatory affections, in persons of a strumous or scorbutic habit. General remediate treatment is seldom required during the dis- ease. When febrile excitement attends, which is rarely the case, a reduction of the diet, with some mild aperient medicine, diluent drinks, with small doses of spiritus mindereri, or sweet spirits of nitre, should be ordered. In some instances, the inflammation and swelling around the pustule become so great as to demand particular attention. This is most apt to happen when the vesicle is irritated by scratching or rubbing it, at the time when the areola is about making its appearance, more especially when at the same time some 454 VACCINA. other cause supervenes, calculated to produce general febrile irrita- tion. To moderate the violence of the pain and inflammation, a weak solution of sugar of lead, or cold water, or poultices made of lead-water, may be applied to the inflamed part, and laxatives, with some of the milder refrigerant diaphoretics given internally. With regard to the prophylactic, or protecting powers of the vac- cine disease against the small-pox, the opinion of the profession has undergone considerable change within the last ten years. It seems to be pretty generally admitted at present, that the vaccine affection, even in its most perfect state, does not so completely protect the system from the variolous infection, as was formerly so confidently believed. From whatever cause it may proceed, it is beyond a doubt, that the failures of vaccination in preventing secondary small- pox, "have been steadily and progressively on, the increase for some years past" "This circumstance," says Dr.LGregory, " can- not be met by a reference to the fact, that small-pox once gone through, does not always protect the.subject from a second attack." Cases of small-pox after vaccination, are far more frequent than second attacks of small-pox. Dr. Gregory has given a table of the total number of admissions into the small-pox hospital in ten differ- ent years, and from this statement, it appears that in the year 1810, the proportion of cases of small-pox after vaccination, to the whole number of admissions, was as 1 to 30; while in 1815, it was as 1 to 17; in 1819, as 1 to 6; in 1821, as 1 to 4; and during the year 1823, as I to 3i. Notwithstanding these facts, vaccination must still be regarded as an invaluable means for lessening the amount of mortality, and as deserving all confidence as a protecting power against small-pox. For although it may not, in many cases, render the system wholly insusceptible to the variolous infection, yet the number of instances in which it affords perfect immunity from small-pox, is beyond all comparison greater than that in which it fails to afford complete protection; and even where it does not entirely subdue the suscep- tibility to the small-pox, it almost invariably lessens it to such a de- gree, as to render this latter disease so mild and simple, as in most instances scarcely to require any remediate attention. It is believed by many, that the constitutional influence of the vaccine disease gradually diminishes, until the system, though at first protected by it against the variolous contagion, regains in the course of years its original susceptibility to small-pox; and this opin- ion is in fact strongly countenanced by the results of experience. Some have supposed that the vaccine impression continues only about ten years; others have limited its duration to seven years; and Dr. Leo Woolf, in an interesting memoir on this subject, has adduced facts and reasonings to show that this influence is ef- faced by the constitutional changes which occur at the age of pu- berty. That the prophylactic influence of the disease suffers pro- gressive diminution until it becomes, perhaps, wholly effaced, I MODIFIED SMALL-POX. 455 am myself much inclined to believe, from facts which have come under my own observation; but the attempt to set any precise limits within which the gradual subsidence of this influence is accomplished, must necessarily be attended with great uncertainty; since it may well be supposed, that idiosyncrasy, modes of living, and acciden- tal as well constitutional predispositions, and perhaps habitual ex- traneous influences, may give rise to much variation in this respect. From the general fact (if in truth it be so) that the constitutional impression of vaccination wears out in the progress of time, many physicians have of late recommended re-vaccination, so as to renew its impression on the system; and this practice may be deemed a reasonable, and certainly not a detrimental, precautionary measure. Various modes have been proposed to test the sufficiency of a recent vaccination, as a protective power against the small-pox in- fection. For this purpose, some have advised re-vaccination five or six days after the first operation. If the disease is perfect in its influence, a vesicle will rise at the point of the second vaccina- tion, but it will differ in its progress from the first, by becoming surrounded with a complete areola, as early as the second or third day of its appearance, so that the areolae of the first and second vesi- cles commence nearly at the same time, and progress pari passu. Others have proposed to re-vaccinate about the end of twelve days from the first vaccination. If the first has been perfect, the second vaccination will either not succeed at all, or give rise only to a spu- rious or irregular pock. The most certain test, however, is inocu- lation with small-pox matter—a test from which we derive at once our reliance in the general protecting powers of the disease, and in the genuineness of the particular instance. A distinct, circular, radiated, punctulated, and not very large cicatrix, may be regarded as a pretty certain indication, that the vaccine affection was perfect. When, on the other hand, the scar <•>►© ©»««.— CHAPTER XVII. MINOR EXANTHEMATA. Sect. I.—Herpes. The term herpes, was formerly applied in a very vague manner; and the German writers still include under its head various chronic affections of the skin, which by the late English and French writers, are regarded as wholly diverse from each other.* Willan first em- ployed it in a different manner, and restricted its application to a distinct class of cutaneous affections, characterized by an eruption of vesicles, appearing in groups or clusters on an inflamed sur- face, "so as to present one or more distinct spots separated from each other by intervals of sound skin." In most instances, mani- fest constitutional disorder, such as languor, loss of appetite, restless- ness, and occasionally febrile symptoms, with a burning or stinging sensation, or deep-seated aching pain in the affected parts, precede * Richter arranges ptyriasis, psoriasis, ecthyma, and various species of impeti- go with the herpetic affections. His fourth species, herpes pustulosus, comprehends the five varieties of herpes of Willan. The minute splitting of diseases, so com- mon of late, may be regarded as of very doubtful advantage, both in a scientific and practical point of view. A careful comparison of many of these species— their variable character, and their frequent conversion into each other—shows at once the little foundation there exists for at least some of these subdivisions. The affections arranged under the term herpes, by Willan, and others, are how- ever sufficiently distinct in their character, and diverse from other analogous dis- orders, to require separate consideration; and it is of little consequence what name they bear, provided they are properly described and understood. 510 HERPES PHLYCTENODES. the appearance of the eruption. There is a regular increase, matu- ration, and decline, in the progress of the eruption, but the duration of its course varies from one to three weeks. The fluid in the vesi- cles is at first limpid, becoming opaque or whey-like and more vis- cid as the disease advances, and at last either concretes into brown crusts, or the vesicles break, and suffer it to escape, giving rise often to disagreeable and unmanageable ulcerations. The diagnosis of herpes is founded on the assemblage of the ve- sicles in separate clusters, the red or inflamed state of the skin upon which they are seated, and the natural colour of the intermediate spaces of skin. These characteristics distinguish it sufficiently from erysipelas. From tetter (impetigo,) eczema, and other forms of chronic eruptions, it differs in its purely vesicular form, its more acute character, and particularly in the regular progress of the vesi- cles from their incipient transparent state to maturation, and finally scabbing. Herpes admits of being divided into different varieties, according to the particular form of the vesicular clusters, and the part of the body upon which they appear. 1. Herpes Phlyctenodes. This variety of herpes may occur on all parts of the body, having no determined form or seat. The appearance of the eruption is usually preceded, for several days, by slight febrile symptoms, and these sometimes continue after the vesicles have come out. On the part which is about to be the seat of the eruption, we may at first notice a multitude of very minute red points. In the course of twenty or twenty-four hours more, the skin upon which these points appear, becomes uniformly red, and small transparent vesicles make their appearance. The cutaneous efflorescence extends a few lines beyond the margin of the vesicular group; and the vesicles them- selves are firm and resisting to the touch during the first day. A sense of smarting, and occasionally a dull and severe pain, accompa- nies the appearance of the eruption.—(Cazenave.) The eruption most commonly occurs on the upper parts of the body, particularly on the neck, breast, arms, and cheeks. It con- sists of small transparent vesicles, aggregated into irregular clusters of various sizes, from a few to nine or ten inches in circumference. These vesicles are sometimes very minute, and at others they are as large as a small cherry. In some instances they come out at first on the neck or breast, " and gradually extend over the trunk to the lower extremities, new clusters successively appearing for nearly the space of a week." This gradual extension of the eruption oc- curs very rarely, however, except in cases where the vesicles are very minute. In general, the eruption is confined to one or two groups when the vesicles are pretty large. About the fourth or fifth day the vesicles either burst and give exit to the included fluid, or HERPES ZOSTER. 511 they begin to wither and concrete into yellowish scabs, which usu- ally fall off about the eighth or tenth day, and leave a red and irrita- ble surface. When the eruption appears in successive groups on different parts, the disease will of course be proportionably pro- longed; for each cluster passes regularly through its stages of matu- ration and scabbing. However contiguous the groups of vesicles may be to each other, the intervening skin always retains its healthy appearance.—(Bateman.) Diagnosis.—The only affection with which the present form of herpes is particularly liable to be confounded is pemphigus; but an attention to the circumstance that the vesicles in pemphigus are usu- ally large, and always isolated—or at least not aggregated in clus- ters; and that they are very rarely attended with a red or inflamed basis, (unless where the bullae are nearly in contact with each other) will enable us without difficulty to distinguish these affections. Causes.—Children, and young and robust persons, appear to be most liable to this affection; but of itsjpredisposing and exciting cau- ses we have no definite knowledge. Cold, improper nourishment, or an excess of food, grief, watching, and irritation in the primae viae, have been supposed to exercise an agency in its development. 2. Herpes Zoster.—Shingles, Zona. This disease bears a very close resemblance to erysipelas, and was generally regarded as a mere variety of this affection, until Willan pointed out its distinctive characters, and placed it with the herpetic eruptions. This form of herpes is characterized by a band of vesi- cles, seated on a red or inflamed surface, commencing usually either in the right hopochondrium or lumbar region, and extending like a belt towards the fore part of the abdomen, without however crossing the median line. In some instances this band of vesicles passes down to the groin; in others it passes upwards to the inferior angle of the scapula, and sometimes extends to the internal part of the arm, " running down occasionally to the cubital border of the hand." This eruption does not often occur on the left side of the body; in- deed I have seen but very few instances, of its location on this side. Velpeau,* and Brendel, however, assert the contrary. The former saw but one instance of its occurrence on the right side, out of thirty cases. The majority of writers, nevertheless, affirm that it gene- rally makes its appearance on the right side, and my own experi- ence is strongly in favour of this observation. It has never been found to occur on both sides at the same time. These vesicular zones are composed of irregular groups, from one to two or three inches in diameter; and where the clusters are not very close to each other, the intermediate skin retains its healthy colour. The extension of the band does not occur by a regular succession of vesi- * Revue Medicale, December, 1828. 512 HERPES ZOSTER. cles, but by successive new clusters coming out nearly in a line with the first. This, like the preceding variety of herpes, is gene- rally preceded for a few days with loss of appetite, lassitude, slight headach, nausea, more or less febrile irritation, " together with a scalding heat and tingling in the skin, and shooting pains through the chest and epigastrium." In some instances, however, little or no constitutional symptoms can be perceived.* At first vividly red blotches appear arranged into an irregular belt, a short distance from each other. Upon these inflamed surfaces, a number of small whit- ish points appear, which soon increase in size, and become distinct transparent vesicles " of the size and appearance of small pearls." These vesicles increase in magnitude until the third or fourth day, when they acquire a yellowish or milky appearance, and on the fol- lowing day begin to shrivel, at the same time that their bases acquire a darker red, or bluish colour. The vesicles about this time break and discharge a viscid serous fluid which dries into brownish crusts, which fall off about the tenth or twelfth day. Sometimes excoria- tions and occasionally superficial ulcerations occur, leaving strongly marked cicatrices. The disease does not, however, always pursue this regular course. In some instances the vesicles dry up about the fifth or sixth day— the fluid in them being absorbed—and terminate without scabbing, by desquamation. In old and enfeebled subjects, the eruption has been known to terminate in gangrenous ulceration of the skin. Causes.—Zona is most apt to attack young persons;t and it is said to occur more frequently in males than females. (Bateman, Cazenave.) Reil asserts that this affection has never been observed in children under three years old. It seems occasionally to arise from the influence of cold; and some have ascribed its occurrence to irritation of the urinary organs. (Reil.) Disorder or irritation * Cazenave and Schedel observe, " we have seen a great number of instances of zona in the Hospital St. Louis, and have never seen it accompanied with those general symptoms, and particularly of a gastric nature, with which it has been asserted it is always attended; a state of uneasiness, in some rare cases a slight excitement of pulse, heat of the skin, a sensation of tension, which is generally painful about the seat of the eruption, acute pain in those parts where the dis- ease terminates in ulceration, and finally a slight local pain, remaining some time after the eruption has disappeared, (not acute as has been said,) are the only phenomena, which, in a majority of cases at least, accompany this variety of herpes."—Practical Synopsis, p. 104. t We often meet with perplexing discrepancies in the statements of different writers, on points, too, which are matters of mere observation. Thus, in the present instance, Reil's observations are directly opposed to those of Willan, Batelnan, Cazenave, and others. " Of the causes of zona, we know at least that those who are most subject to it are old and cachectic persons, with a relaxed skin and visceral disorders." Fieberlehre, bd. v. p. 399. My own observations, however, lead me to the opinion expressed in the text upon this point. HERPES ZOSTER. 513 of the primae viae, and perhaps of the biliary organs, has appeared to me in some instances to be at the root of the disease. It is said to have prevailed epidemically. (Cazenave.) Prognosis.—This form of herpes is but rarely attended with se- vere symptoms. When it terminates in ulceration it may become troublesome; and the occurrence of gangrene, which, however, is very uncommon, will of course be attended with more or less dan- ger, according to its extent and the patient's constitutional vigour.* Treatment.—The treatment of herpesphlyctenodes and zona, is to be conducted on the same principles. Gentle aperients, a simple and unirritating diet, and rest, will, in general, suffice for the con- stitutional treatment. When there is considerable restlessness, and some degree of febrile irritation, we may prescribe mild diaphore- tics and cooling acidulated diluents. Where there is reason to suspect gastric or biliary irritation, minute portions of calomel and ipecacuanha will be proper. The warm bath will also be useful to allay restlessness and dispose to a regular action of the skin. Occa- sionally the arterial excitement is such as to warrant small abstrac- tions of blood by venesection or leeching. Reil recommends par- ticular attention to the renal functions, and advises diuretics where the urinary secretion is scanty. Where there is much deep-seated pain, we may use full doses of Dover's powder with benefit. Bateman considers external applications unnecessary during its vesicular state; and Cazenave asserts that " they are useless." My own experience has led me to a different conclusion. It is indeed true, that " saturnine and other similar astringent lotions" are of little or no service. I have, however, uniformly found the applica- tion of a solution of lunar caustic, in the proportion of six or eight grains to an ounce of water, when employed soon after the vesicles appear, to arrest the progress of the eruption, and cause desquama- tion in the course of three or four days at furthest; and sometimes much earlier. I have never known the slightest inconvenience to result from this practice. I keep this solution constantly applied to the affected part, by strips of linen or flannel saturated with itt M. Velpeau, also, has expressed the most favourable opinion of the powers of this application, in zona. He affirms that when applied before ulceration has taken place, it never fails to arrest the progress of the malady, and so far as he has observed, always without unfa- vourable consequences.^ * In relation to the prognosis of this affection, we find very different sentiments expressed by the old writers. Pliny, Lannge, Dr. Hoffmann, and Shulze, con- sidered it as a dangerous disease; whereas Burserius, Vogel, Lorry, and Diel assert the contrary opinion.—Reil, loc. cit. vol. v. p. 400. j- The lunar caustic was, I believe, first used as a local application in this af- fection, by M. Geoffroy.—Revue Medicale, April, 1820. £ Loc. citat. p. 435. Vol. I.—65 514 HERPES CIRCINATUS. 3. Herpes Circinatus.—Ring-worm. This form of herpes is easily recognized by the annular arrange- ment of its small vesicles. It commences with slight redness and itching, succeeded by a circle of minute globular vesicles closely set together, which, when closely examined, are found to contain a colourless fluid. These corona? of vesicles vary from an eighth of an inch to two inches and upwards in diameter, and the larger ones leave the central portion of the skin apparently in a natural state. The vesicles break in four or five days after their appearance, and are succeeded by little prominent, brownish, and thin crusts or scales, which in the majority of cases fall off about the eighth or ninth day, leaving a red surface which gradually disappears. Occa- sionally the whole disk of the circle is somewhat inflamed, " and a slight desquamation occurs without the formation of vesicles." When the circles are very small, the eruption withers, and gradu- ally exfoliates without the formation of crusts or scales. Although the eruption is seldom protracted beyond the tenth day, yet in many instances new circles of vesicles appear, in succession, so as to pro- long the whole course of the disease for several weeks. The erup- tion is always attended with a troublesome itching and tingling sen- sation. This variety of herpes is most frequently met with in children, and occurs generally on the arms, shoulders, breast, and especially on the neck and face. This disease must not be confounded with a somewhat similar affection which occurs only on the scalp, (porrigo scutulata,) and which is familiarly known by the term hair-worm. This dis- ease is contagious, destroys the hair, and is pustular. Its duration is indefinite and long, and it gives rise to the formation of thick adherent scabs. There is a variety of ring-worm, not noticed in the work of Caze- nave, though described by Bateman, which is by no means uncom- mon in this country, and which often continues for many months, and at last takes up a large extent of surface. It commences with a small circle of vesicles, like the form just described. This circle, however, gradually enlarges its circumference, by the successive appearance of new vesicles around the external margin of the ring, whilst those situated on its internal margin heal and desquamate. Treatment.—The treatment is almost exclusively local. Alka- line washes, such as a lotion of from one to two drachms of subcar- bonate of potash or soda to a pint of water; or solutions of nitrate of silver, sulphate of zinc, or of copper. One of the best applications I have met with in this affection, is an ointment made of the root of the common narrow-leafed dock, (rhumex crispa) by boiling the grated root in lard. Mild laxatives should be used if the eruption is extensive. HERPES PREPUTIALIS. 515 4. Herpes Labialis. This is a vesicular eruption which occurs on the upper and under lips, and particularly at the outer angle of the lips, extending some- times nearly round the mouth, and occasionally to the cheeks, alae nasi, and chin. In some instances this eruption appears almost sud- denly, without any previous redness or disagreeable sensation in the part; and at others it is preceded by a slight tenderness or pain, inflammation and swelling of the skin, for three or four hours. The lip generally becomes somewhat swollen, hard, stiff, and tender. The vesicles sometimes " attain the size of a small pea, and are filled with a transparent fluid," which soon becomes opaque, acquiring a straw-colour, or sero-purulent appearance, during the third or fourth day. In the course of a day more they shrivel, and are succeeded by light-brown scabs, which usually separate on the seventh or eighth day. This eruption is always attended with very consider- able heat and smarting, and great soreness to the touch. This variety of herpes does not often occur as an idiopathic affec- tion. It generally appears on the subsidence of slight febrile affec- tions from cold, as well as on the declension of other acute diseases, more especially such as are connected with visceral affections. It may in fact be considered, in cases of this kind, as a phenomenon of crisis, for it is a common, and in general not an incorrect observa- tion, that the occurrence of this eruption indicates the near approach of convalescence. In many instances it is accompanied by coryza, and pain or tenderness in the fauces. It may be produced by irri- tating applications to the lips. The only remediate applications necessary in this affection, are such as palliate the burning heat and pain, when these are trouble- some. For this purpose, fomentations, with a decoction of white poppy heads; or cold water, with a small portion of acetate of lead dissolved in it, may be used. 5. Herpes Preputialis. This variety of herpetic disease, occurs on the prepuce, and may readily be mistaken for chancre, to which indeed it sometimes bears a very close resemblance. It begins with one or more red spots, attended by itching, and a sense of slight heat in the part. Small vesicular elevations soon appear on these inflamed surfaces. When the eruption occurs on the external surface of the prepuce, the vesicles dry up about the sixth day, and are converted into small, firm scabs, which usually fall off by the end of the ninth or tenth day, and leave the skin underneath sound. When the eruptions occur on the internal surface of the prepuce, they generally break out about the third or fourth day, and form small scales, which soon separate, and leave excoriations, passing 516 PEMPHIGUS. sometimes into superficial ulcerations, with white bases, and slightly elevated edges. If left to themselves, or not irritated, these sores continue nine or ten days before they begin to heal, but when they once commence this process, they usually cicatrize rapidly. This affection may arise from the prepuce being chafed by woollen clothing; from the irritation of morbid vaginal discharges; and par- ticularly from suffering the natural secretions of the part to remain between the glands and prepuce. Treatment.—I have generally employed a solution of borax with much advantage in this affection. When the excoriations are slow in healing, a very weak solution of the nitrate of silver is perhaps the best application. I have used this solution in a number of cases with prompt benefit. The chlorite of soda in solution is likewise a very efficacious application in cases of this kind. I have lately em- ployed this lotion in two obstinate cases with marked success. It was first recommended by Lisfranc. I used this article in the pro- portion of twenty grains to an ounce of water, and applied it five or six times daily. Sect. II.—Pemphigus.* The term pemphigus is used to designate a peculiar exanthema- tous affection, characterized by fever, followed in the course of from one to three days with large transparent vesicles, having red and in- flamed bases. The occurrence of such a disease, as an independent or idiopathic affection, has been much doubted by many writers, and some have even denied its existence altogether. Willan, Bateman, Plumbe, Reil, and a number of other writers, contend that the cases which are described by the earlier writers as acute idiopathic pemphigus, were—typhus, pestilential, or other milder forms of fever, attended by bullae, as mere casual symptomatic and unessen- tial eruptions. Gilbert,t and Biett,J on the other hand, admit the occasional appearance of acute pemphigus, as an idiopathic malady. There can exist but little doubt that many of the cases described by authors as pemphigus, were, in relation to their vesicular character, purely symptomatic; for bullae entirely similar to those which are ascribed to this affection, have been known to occur in diseases ob- viously diverse in their general essential characters. They have * The first distinct account that was given of this disease, is to be found in the writings of Piso (observ. 149) and Morton (tract, de morb. acut.) It has since been described under a great variety of names—such as, febris catarrhalis vesicularis, (Delius. amoenitat. med. dec. 1;) febris vesicularis, (Macbride and Selle, prax. medic. 1.11. c. 18;) febrispemphygodes, (Seeliger, Ephemer. N. C. dec. 1, ann. viii. ob. 56;) febrisphlyctenodes, (Burserius;) hydatidu, (de morbis a colluvie serosa orta;) febris bullosa, (Brugmann.) f Monographie sur le Pemphigus. X Cazenave and Schedel. Pract. Synop. of Cutan. Diseases. PEMPHIGUS. 517 occurred in intermitting fever;* in bilious remittents;t in dysen- tery ;X in typhus;§ in various modifications of malignant as well as in arthritic fevers;|| in hysteric affeetions;1T and in the ordinary catarrhal fevers, as well as in various other forms of febrile disease. Cazenave states that he saw a case in the Hospital of St. Louis, in which " this eruption was attended not only with gastro-intestinal irritation, but also with a pulmonary catarrh, an ophthalmia, and a very acute inflammation of the urethra. All these symptoms, together with the eruption, disappeared in the course of a month." It is difficult to conceive upon what grounds he regards this as a case of idiopathic pemphigus; for in its general course and phenomena it is greatly at variance with his previous description of this affection. Most assuredly, if this case deserves to be regarded as an instance of pemphigus, we may with little hesitation admit the many supposed. examples of this disease, which have been reported by different writers (but rejected by Cullen, Willan, Bateman, and Reil) as genu- ine, though modified instances of this affection. Under this per- plexing contrariety of statements and opinions, it is no easy matter to come to any satisfactory conclusion on this head. That the ap- pearance of bullae, or large distinct vesicles, in febrile affections, is often casual or symptomatic, and sometimes apparently critical, is unquestionable;** but it is nevertheless difficult to deny, merely from this general fact, that they may appear in an acute form as an idiopathic or independent malady. Whether, however, this erup- tion be always, or only generally symptomatic, I shall now describe it, as it has been observed and recognised for genuine acute pemphi- gus, by several recent writers, who must have been fully acquainted with the doubts expressed on this subject by Cullen, Willan, and others, and who, we may therefore presume, were better prepared to estimate the character of the disease than the earlier writers. Pemphigus appears under two distinct forms: the acute and the chronic. The latter form is described by Willan, Bateman, and other late writers, under the name of pompholix. Symptoms of acute pemphigus.—The disease commences with symptoms of general indisposition, or more or less febrile irritation. In some cases, the precursory symptoms amount only to a feeling of general languor and uneasiness, with slight acceleration of the pulse, * Braune. Versuch fiber den Pemphigus, &c. Leipzig, 1795. t Salabert. Abhandl. fur pract arzte, vol. xiii. X Bontius. De Medic. ./Egyptiorum. Rengger. Museum der Heilkunde, Zurich, 1794. § Medecine Experimentale. || Hufeland's Journal, vol. xi. p. 138. If Frank. Epitome, tom. iii. p. 269. ** Frank saw an instance of inflammatory fever, in which, after the fifteenth venesection, a critical pemphigus broke out.—De Curandis, Horn. Morb. L. Ill, p. 265. 518 PEMPHIGUS. and itching of the skin. In others, nausea, loss of appetite, slight chills, increased thirst, and great frequency of the pulse, with a hot and burning skin, precede the eruption. At an indefinite period from the commencement of these symptoms—varying from one to four days—the eruption makes its appearance. At first, small red circular spots come out, which speedily increase in size, each one be- coming covered with a transparent vesicle. These vesicles or bullae are of a circular form, and vary from the size of a pea to that of a large hazelnut. Sometimes the bullae are much smaller than the red spots upon which they are seated, leaving a considerable inflamed margin around their bases; at others, they cover nearly the whole surface of the circular spots, with only a very narrow line of red border. Cazenave and Schedel seem to regard these red areolae or bases as invariably present and strongly characteristic of acute pem- phigus. Richter, however, observes, that the bullae sometimes ap- pear to rise out of a sound skin, without the least redness around their bases. Some spots occasionally appear on the skin which do not vesicate; but to the touch they will be found slightly elevated, " and when they are rubbed for a short time, the cuticle becomes detached, and a slight exudation of serous fluid takes place under it." The bullae increase in size during the first twenty-four hours, and the contained fluid, at first limpid, becomes yellowish, and finally turbid.* They sometimes break on the second day; but much more commonly they remain in a turgid state to the end of the third or beginning of the fourth day, when the fluid begins to be absorbed, and the vesicles shrivel, leaving either thin brownish crusts, or only "small dry white epidermic lamellae," which in a few days longer separate, exposing pale red surfaces.! If the bullae are broke at an early period, they sometimes rise again, but more frequently super- ficial suppurative ulcerations ensue. (Richter.) The occurrence of the eruption has no manifest influence on the general symptoms, the fever continuing usually without any obvious change until the bullae begin to wither. (Richter.) The eruption may come out on any part of the body, and either occupy only a particular region, or appear scattered over the greater part, or the whole surface of the body. In most instances, however, the bullae are confined, at first to a single part; when these begin to disappear, another crop comes out on some other portion of the body; and in * This fluid has been noticed acrid or irritating, like the tears in violent catarrh. Occasionally it is reddish, as if a small portion of blood were mixed with it. Very generally, however, it is perfectly bland and unirritating, at least in the early period of the eruption.—Richter, Specielle Therapie, bd. ii. p. 604. f The spots left by this eruption are said to be peculiar. " We have several times seen M. Biett draw a diagnosis from them as to the previous existence of bullar eruption, which had been cured some time before. They are of a dull red colour, separated from each other, of an irregular form, of variable size, and form slight exfoliations from time to time."—Cazenave and Schedel, I. c. p. 129. PEMPHIGUS. 519 this way, two or three successive eruptions may take place, so as to protract the whole course of the disease, sometimes to a period of between two and three weeks. The internal mucous surfaces, also, are liable to become affected, particularly the mouth, fauces, and oesophagus, and probably the mucous membrane of the alimentary canal. The pompholix solitarius of Willan, is, according to Cazenave and Schedel, a mere variety of acute pemphigus. This is an ex- tremely uncommon form of the disease, and may assume a more or less chronic character, although its usual duration is from eight to ten days.* Willan says that it seems to be entirely confined to females. A sensation of tingling of some portion of the skin is at first felt; this is succeeded by one large vesication, (appearing usu- ally at night,) which is rapidly filled with a transparent colourless lymph. This large bulla breaks in the course of forty-eight hours, and leaves a superficial ulceration. In a day or two a second vesica- tion occurs near the first one, which runs through the same course; and a third or even a fourth one may rise in succession, so as to protract the disease to the ninth or tenth day. (Bateman.) Chronic pemphigus.—Willan and others who deny the existence of acute idiopathic pemphigus, describe the present variety of the disease as a distinct affection, under the term pompholix. They assert that the bullae appear " without any inflammation around them, and without fever." This, says Richter, is not entirely incorrect. In many cases the disease commences with distinct febrile symptoms, which continue occasionally until the first eruption is completed; and in some instances the slight fever reappears afterwards, when- ever a new and numerous eruption of bullae is about to take placet In almost all cases, the patient experiences a slight degree of lassi- tude, pain in the limbs, and languor, for several days previous to the appearance of the eruption. Nor does the observation that the bullae are always " without any inflammation around them," appear to be correct, for in some instances " the secondary eruptions have erythematous areolae." (Cazenave.) The bullae begin by small red elevated points, on the centre of which the epidermis becomes speedily raised. These rapidly enlarge " into irregular vesications, acquiring often in a few hours the size of a hazelnut or even a wal- nut." If they do not break, they begin to shrivel about the third or fourth day, the fluid contained acquiring a reddish and opaque ap- pearance. In a few more, the withered and macerated cuticle dries into thin brownish crusts. If the bullae break at an early period, " the cuticle shrivels, or becoming partly detached, rolls up and lays * Cazenave, Synopsis, &c. p. 124. X Specielle Therapie, bd. ii. p. 613. Reil says that in some cases the febrile symptoms are conspicuous in the commencement, but that these gradually sub- side, leaving only a chronic bullar eruption, which continues often for many months, and even years. Loc. cit. p. 428. 520 PEMPHIGUS. bare a portion of the inflamed surface," or separates entirely, and exposes a painful superficial ulceration. (Cazenave.) This affection is generally very tedious in its course, and may con- tinue for several years. A continual succession of bullae occurs on different parts of the body, sometimes in successive crops, and at others in such a manner, that, at the same time, some will be just appearing, others will be large, and distended with a straw-coloured lymph, and others again shrivelling, or already converted into small crusts. Occasionally the bullae are so numerous that many of them run into each other, and in this case some of them usually become purulent, and on drying up leave thin yellowish crusts extending over a considerable portion of the body. When the eruption is moderate, the patient does not in general experience much inconvenience from the disease; but in cases at- tended with numerous vesications, and particularly where the lymph is somewhat irritating, a burning and extremely distressing itching is experienced, which in violent cases sometimes obliges the patient to keep to his bed. In some instances the vesicles are early attended with severe burning pain, become filled with a red acrid humour, and terminate in superficial suppurative ulcers, which heal very slowly. Reil ob- serves, that bullae, containing bloody lymph, occur only about the ears, where previous vesicles have already occurred.* Wichmann relates a case, in which, nine months after the commencement of the disease, he found the patient extremely tormented and debilitated by a great number of large ill-conditioned ulcerations on the lower extremities and sacral region. The ulcers appeared red, and the surrounding skin as if it had been scalded with hot water.t A some- what similar case is mentioned by Cazenave and Schedel. This affection may occur simultaneously on every part of the body; but in most instances the vesications are confined to a particular space. In the palms of the hands and soles of the feet they occur but very rarely. They have been observed on the internal surface of the mouth, the fauces, oesophagus, and the alimentary canal; in these situations they soon assume the appearance of aphthae. The tongue and fauces occasionally become excoriated in cases of this kind. Colic; constipation; bloody and mucous alvine discharges; nausea; vomiting, or haematemesis, have been known to supervene in cases where the disease affected the alimentary canal. (Wich- mann, Reil.) "At times, it would seem as if the eruption on the external and internal surfaces alternated—the symptoms of the latter increasing as those of the former decrease, and vice versa."X Both Wichmann and Braune relate cases in which the mucous membrane * Fieberlehre, Bd. v. p. 418. X Beitrag zur Kenntniss des Pemphigus. X Braune. Versuch fiber den Pemphigus und das Blaaenfieber. Reil, 1. c. p. 420. PEMPHIGUS. 521 of the bronchiae became affected during the progress of this malady. Several instances are mentioned in which cough and purulent expec- toration came on. Cause.—Of the etiology of pemphigus there is as yet but little known of a satisfactory or definite character. It is said to be more common in old than in very young individuals, and in women than in men.* Braune supposes that this affection is frequently depend- ent on deficient or disordered urinary secretion; (1. c. p. 59.) Ha- bitual deficiency of this secretion, and obstinate chronic cutaneous disorders, are indeed not unfrequently associated affections. In one of the instances of chronic pemphigus mentioned by Braune, the in- timate connexion between the action of the kidneys and the cutane- ous affections was manifested in the clearest manner. Whenever the urine flowed freely, the bullae disappeared; but they invariably re- appeared when this secretion became scanty, watery, and muddy. Renal calculi were discharged from time to time with the urine. Richter, Wichmann, and Reil, also admit the frequent occurrence of renal disorder in pemphigus. It would seem also that disorder of the liver is a frequent attendant on this disease,—whether as cause or effect, is not known. Biett, in his dissections in the Hospital St. Louis, several times met with structural disease of the liver, in per- sons who had died under this disease. (Cazenave.) The irritation of dentition; neglect of personal cleanliness; a defi- cient and coarse diet; habitual exposure to a damp atmosphere; and chronic visceral affections, would seem sometimes to favour the de- velopment of the disease. It arises, however, often, without any perceptible cause, either predisposing or exciting. It is said to have occurred endemically. The same individual may be affected with it several times, at distant intervals. This disease is not contagious. Hall inoculated with lymph taken from the bullae without effectt Diagnosis.—Acute pemphigus is liable to be confounded with rupia simplex, ecthyma, and herpes phlyctenodes. From the first of these affections it differs, by the bullae in rupia being few in num- ber, and followed by ulcerations, upon which thick and projecting scabs are formed. It is distinguished from the second by the bullae in ecthyma being less elevated, and filled with a purulent fluid, having a brownish spot in the centre of each. From the last disease it may be distinguished by the vesicles in herpes always appearing in clusters seated on a diffused red and inflamed surface. Although several bullae in pemphigus are occasionally found collected in one or more groups, yet distinct bullae appear elsewhere on the body, which is not the case in herpes. Prognosis.—The acute form never terminates fatally unless dan- * This at least is in conformity with the observations of Reil and others. Ca- zenave, on the contrary, says that the chronic form of the disease " rarely occurs in women." X Duncan's Annals of Medicine, for the year 1799. Vol. I.—66 522 PEMPHIGUS. gerous secondary affections supervene. In relation to the probable duration, ultimate violence, and obstinacy of the chronic form of the disease, the prognosis is in general very uncertain. Some cases con- tinue moderately for eight or ten weeks, and then disappear; others, apparently equally mild during the first four or five weeks, gradually acquire more and more severity, and continue for many months in an aggravated and very distressing form, and may even terminate fatally. The degree of danger depends, of course, in a great mea- sure, on the extent of the eruption, the obstinacy of its progress, the nature of the visceral affections with which it may be complicated, and the degree of constitutional vigour of The patient. When the vesications assume a livid or bluish appearance, there is much rea- son to apprehend unfavourable consequences. (Reil.) Old, worn down, relaxed, arthritic, and nephritic subjects, are most apt to suf- fer severely from this affection. Treatment.—In the acute form of the disease, it will in general be sufficient to put the patient on a simple and unirritating diet; to prescribe an occasional mild laxative; cool acidulated diluents; rest; and to avoid a humid and variable atmosphere. If inflammatory symptoms supervene, or the eruption is very extensive, a more active antiphlogistic treatment is required. Gentle purgatives; the ordinary saline diaphoretics, particularly the alkaline effervescing draught (potio Riverii;) tepid bathing; and venesection, must be used with an energy corresponding to the degree of the general and local inflammatory excitement present. Richter recommends calomel in such cases above all other aperients. He also advises the use of diuretics, if the disease manifests a disposition to continue beyond its ordinary course—and of these, he says, digitalis is the best, squills being, according to his experience, objectionable. All local applications must be avoided, nor should the vesicles be disturbed or opened. Cazenave recommends the application of leeches to the anus. In chronic pemphigus, (pompholix,) we should in the first place endeavour to ascertain whether any visceral or other general disor- ders co-exist, or preceded the eruption. Should there be grounds for presuming the presence of a syphilitic taint, or of an arthritic or calculous diathesis, or finally of hepatic or some other visceral affec- tion, recourse should be had to remedies suited to counteract the lurking affection. (Richter.) In general, a moderately antiphlogis- tic treatment—such as acidulated diluents, mild aperients, and tepid baths, will be proper in the commencement. The German writers speak very favourably of the employment of diureticsin this variety of the disease. They are particularly indicated where the urinary secretion is scanty or unnatural. Richter says that he cured an in- veterate case in a short time by the following mixture,* in conjunc- * R.—Extract, digital, purpur. gr. iii.—iv.—vi. Submuriat. hydrarg. mitis gr. i. URTICARIA. 523 tion with the free use of an infusion of juniper berries. The same writer recommends dulcamara, in union with antimony* Lime- w-ater in large portions; infusions of herba jacea; sarsaparilla; preci- pitated milk of sulphur; belladonna; and opium, have all been men- tioned as remedies in this affection. I have met with but one case of chronic pemphigus. It continued for six months, under various modes of treatment, and at last disappeared under the use of Fowler's arsenical solution. When diarrhoea, with more or less obtuse ab- dominal pain, supervenes, opium is particularly serviceable. When pulmonary irritation occurs, attended with frequent and violent cough, spitting of blood, and oppressed respiration, local and general bleeding becomes necessary, after which opium and calomel may be administered with benefit. When, by the long continuance and severity of the disease, the strength of the patient is exhausted, or when the disease occurs violently in old, relaxed, and worn down subjects, quinine, with the sulphuric acid; a nourishing diet; occa- sional opiates; chalybeate preparations; and other supporting reme- dies, should be employed. Cazenave and Schedel state that they have observed several examples in the Hospital St. Louis, of the very good effects of tonic remedies even in young subjects, where the eruption was of long continuance. Sect. III.— Urticaria.—Nettle-rash. The nettle-rash, a very common cutaneous affection, is character- ized by hard elevations of the cuticle, of irregular forms, with a pale or whitish centre, and generally a diffuse redness round their mar- gins, attended with intolerable itching, and a stinging or smarting pain. Its course is often very rapid, the eruption appearing suddenly, and vanishing again in the course .of a few hours; although in such cases, it usually reappears for several days in succession. It may also assume a chronic character, and continue with occasional tran- sient intermissions or remissions for many months, or even years. Urticaria febrilis.—Symptoms of general indisposition, such as nausea, languor, drowsiness, slight chills, headach, anorexia, pain and anxiety in the epigastrium, with an accelerated pulse, precede Opii. puriss. gr. ss. Saccb. albi. gr. xv__M. Divide into twelve equal parts. S. Take one three times daily. The proportion of digitalis should be gradually increased. If the gums become affected, the use of the medicine must be suspended for a while.—Loc. cit. p. 615. * R.—Antimon. crud. nigri. Pulv. stipit. dulcamar. aa 5ji. Extract, trifol. aquat. 311.—M. Divide into two grain pills. S. Take ton three times daily. 524 URTICARIA. the appearance of the eruption. At first, a general itching with a feeling of tingling heat is felt over the whole body; to relieve which, the patient is apt to rub or scratch the skin, which never fails to bring out, almost instantaneously, large patches of red elevations or wheals, with whitish central disks and irregular crimson areolae, attended with an extreme degree of itching and tingling. The erup- tion speedily becomes more or less extensively diffused over the surface, particularly on the palmar aspect of the fore-arms, around the knees, along the loins, on the inner part of the thighs, and on the shoulders. The irruption vanishes irregularly on different parts of the body, but is almost immediately recalled " on any part of the skin, by strong friction or scratching." During the day the erup- tion subsides, but as the evening approaches, it returns, together with slight febrile irritation; and in this manner the disease is usu- ally protracted to the sixth or seventh day, before it finally subsides. The parts principally affected become swollen and uniformly red; but the swelling always soon subsides after the eruption disappears. More or less languor and febrile irritation accompany the disease throughout; " the disorder of the stomach, however, is relieved by the appearance of the eruption, but returns whenever the eruption reappears." (Bateman.) Urticaria cvanida.—This variety of the disease is unattended by fever, and often continues for many months under a succession of transient w7heals, appearing here and there on the body, and vanish- ing again in a few hours, at short and irregular intervals. An erup- tion will perhaps appear on one arm in the morning, and disappear again in a few hours; in the afternoon, the wheals may come out on the legs and remain for a short time; and after a short interval, or only on the following morning, they may appear on the body. In this way the disease may go on to a very protracted period—the eruption appearing and disappearing frequently, " according to the temperature of the air or the exposure of the patient, and the degree and kind of exercise which he uses." The slightest friction or scratching will almost immediately bring out the wheals on any part of the body; but when thus excited, they usually recede again in a very short time. The eruption consists of irregular patches slightly raised and firm to the touch, or of elongated wheals, " like those produced by the stroke of the whip, or they are round, resembling the firm, elevated tumours produced by the bite of a mosquito." These wheals are not surrounded by an erythematous areola, although sometimes encircled by a very narrow and faint streak of red. They are always attended with violent itching, and a sensation of tingling or stinging pain, more particularly "on undressing and get- ting into bed." Languor, headach, transient pains, and derange- ment of the digestive functions, are apt to occur during the course of the disease; but in some instances scarcely any symptoms of con- stitutional or sympathetic disorder, except the cutaneous affection, URTICARIA. 525 attend. " Its course varies from a few days to many months, and even years." (Bateman.) Urticaria tuberosa.—This rare variety of the disease is charac- terized by hard, prominent wheals, or tuberosities, attended with deep-seated pain, tension, and difficulty of motion. The eruption occurs chiefly on the loins and on the extremities. It generally comes out at night, and disappears before morning, leaving the patient "weak, languid,and sore,as if he had been bruised or much fatigued." Cazenave and Schedel state that they saw at the Hospital St. Louis, an instance accompanying a quotidian fever, which, after having lasted for four years, finally terminated " in swellings, great disten- tion, ecchymosis, ruptures, and ulcerations." Some paroxysms were attended with so much general tumefaction, as to produce op- pressed and hurried respiration, a livid and puffed face, weak and intermitting pulsation of the heart, and other very alarming symp- toms. Urticaria subcutanea.—In this variety the wheals seem, as it were, to lurk beneath the skin, and make their appearance only at distant intervals. An almost constant tingling sensation, however, is felt in the skin, with occasional severe pricking sensations, as if needles were thrust into the surface, limited at first to a single part, but extending afterwards to others. Individuals affected with this variety of the disease, are apt to suffer frequent pain in the stomach, and cramps in the muscles of the legs. (Bateman.) Causes.—Urticaria is most commonly met with in children, young females, and in persons of a sanguine and nervous temperament. The seasons most favourable to its occurrence are spring and sum- mer. Some individuals are so strongly predisposed to the disease, that the least friction or scratching almost immediately brings out large wheals. The irritation of dentition, mental excitement, and various articles of food, such as strawberries, raspberries, mush- rooms, honey, oatmeal, green cucumbers, almonds, dried or smoked fish, lobsters, shrimps, crabs, and particularly muscles, are apt to produce febrile urticaria in some individuals. The internal use of valerian and balsam copaiba produce extensive urticaria in some persons. Chronic urticaria is frequently connected with an irritable and deranged state of the digestive functions. The tuberous variety " seems to be excited by excess in diet, overheating by exercise, and the too free use of spirits." Urticaria is also produced by direct irritating applications to the skin, particularly by the leaves of the common nettle (urtica dioica) and by the contact of certain caterpillars, as the phalsena processionacea. It occurs sometimes in the course of various febrile diseases, and is often speedily produced by taking a draught of cold water after the body has been excited or heated by exercise. In many instances, however, the disease makes its appearance without any manifest exciting cause; and its occa- sional dependance on peculiar idiosyncrasy or constitutional habit is unquestionable. In children it often occurs during the process of 526 URTICARIA. dentition, or apparently from acidity in the primne viae, and is in them usually called hives. Prognosis.—Although often an extremely tormenting affection, from the intolerable itching and stinging pain which attend, urticaria is almost universally wholly devoid of dangerous consequences. Werlholf, indeed, observes, that it has in few instances terminated fatally; but death probably occurs only where the eruption is secon- dary, and associated with some other more serious malady. Richter says that in children the disease is sometimes accompanied with great difficulty of breathing. The sudden recession of the eruption does not appear to give rise to any unfavourable consequences. Treatment.—In the febrile variety of the disease, advantage may sometimes be obtained from an emetic of ipecacuanha. Richter states that the operation of an emetic will occasionally put a speedy stop to the progress of the disease. In general, however, one or two mild laxatives, Test, simple diet, cooUng drinks, and the occasional use of the tepid bath, will be sufficient. Where there are symptoms of acidity in the primae viae, magnesia or alkaline remedies, particularly lime-water, will be proper. When the disease occurs in irritable and debilitated subjects, or in persons of weak and disordered digestive powers, benefit may be derived from moderate doses of quinine, sul- phuric acid, and the usual preparations of iron, after the alimentary canal has been evacuated by emetic and laxative remedies. Reil says, copious draughts of cold water often produce a very good effect. In the chronic variety of urticaria, particular attention should be paid to the diet; for, in some instances, it would seem to depend on some article of food rendered oppressive or irritating to the stomach by constitutional habit or idiosyncrasy. " I have," says Wilkn, " desired several persons affected with chronic urticaria, to omit first one, and then another article of food or drink, and have thjus been frequently able to trace the cause of the symptoms. This appeared to be different in different persons. In some, it was malt liquor; in others, spirit or spirit and water; in some, white wine; in others, vinegar; in some, fruit; in others, sugar; in some, fish; in others, unprepared vegetables." Almost all the useful diaphoretic alterative remedies, such as sarsaparilla, the root of burdock, the golden sul- phuret of antimony, dulcamara, Lisbon diet drink, &c. have been at times recommended, but they rarely appear to afford any particular advantage. Fowler's solution, however, is a very efficacious remedy in the chronic form of the disease. It is mentioned by Cazenave as having been successfully used in a very obstinate and distressing case of this kind. Dr. Dewees has used it frequently with success, and I have myself employed it in a few obstinate cases with the happiest effect. To relieve the extreme itching, various external applications have been recommended. Vinegar and water, or lemon juice diluted with water, will sometimes procure considerable relief. The tepid bath also, may be used as a palliative for this purpose. Sea-bathing, or MILIARIA. 527 washing with salt water, has been used with good effect, both as a palliative and a curatiye means. Dusting the affected part with rye- meal or hair powder, gives some relief from the itching and tingling. Sect. IV.—Miliaria.—Miliary Fever. This is a febrile affection, characterized by an eruption of acu- minated vesicles, of the shape and size of millet seed, more or less thickly scattered over the surface of the body. These minute vesicles are at first red, and surrounded with erythematous areolae, which run into each other when the eruption is copious, and give a uniform vivid redness to the surface, (miliaria rubra.) In the course of from twenty-four to forty-eight hours, they enlarge, and the contained fluid becomes whey-like, giving them a white or pearly appearance, (miliaria alba.) When the vesicles are very numerous, some of them unite, and form here and there vesicles of the size of a pea; and on some parts they are closely grouped into irregular patches of various sizes. In a few instances, some of these confluent vesicles become filled with a purulent fluid, (miliariapurulenta.) In some cases the eruption retains its red colour throughout; and occasionally the vesicles are white from the commencement. The miliary eruption appears in general as a symptomatic exan- theme in various forms of fever; " in continued, remittent, inflamma- tory, and contagious, as well as other diseases;" and it has been much doubted whether it ever occurs as an idiopathic or independent malady. Bateman says, that " it is perhaps invariably symptom- atic;" and this would seem to be the general sentiment at the present day. Cazenave, nevertheless, asserts," that there are instances where it is idiopathic, as when it occurs in persons in good health, after violent exercise during the heat of the summer;" and Richter ex- presses the same opinion. The appearance of the eruption is almost always preceded by pre- monitory symptoms; such as a sense of anxiety in the epigastrium;* weight and oppression in the breast, accompanied with a short dry cough; pains in the loins and extremities; a benumbed prickling sen- sation in the fingers; stinging, itching, and burning pain in the skin; a small, frequent, contracted, and tense pulse; cephalalgia; vertigo; ringing in the ears; and a feeling of heaviness in the head; creeping chills; disposition to syncope; palpitation; twitching of the tendons; delirium. The most characteristic phenomenon, however, is the pro- fuse sour rank sweat, which is said almost invariably to occur just before and during the appearance of eruption. Sometimes, however, the miliary vesicles come out without any precursory symptoms whatever.* The eruption always appears first on the neck, breast, and on the inner surface of the arms; and then successively on the abdomen, back, and inferior extremities. The duration of the erup- * Richter, Specielle Therapie, Bd. ii. p. 511. 528 MILIARIA. tion is very variable. In some instances it disappears as early as the fifth or sixth day; but in the majority of cases desquamation does not take place until the ninth or tenth day, and occasionally not until a still later period. Not unfrequently the eruption of vesicles is re- peated twice, thrice, and even a fourth time, so as to protract the whole course of the disease to the sixth or seventh week. In most instances new vesicles appear daily for five or six days, and longer. This eruption appears to be peculiarly liable to recede from the slightest causes; and the consequences of a sudden retrocession are often extremely alarming. Great anxiety in the praecordial region; extreme restlessness; increased febrile irritation; violent delirium; coma; or strong pulmonary congestion with distressing dyspnoea, are among the consequences which are apt to result from this accident. If under these symptoms the eruption do not reappear, or copious diarrhoea, or some other evacuation, do not ensue, a fatal termination will be almost inevitable. (Richter.) This eruption does not appear to be the effect of critical effort in the system, or in any degree to diminish the general symptoms, if we except those miliary vesicles which sometimes occur towards the termination of rheumatic fever and gout* Causes.—That the miliary eruption is, generally, an artificial dis- ease, has been long ago fully established. In the latter part of the seventeenth, and the commencement of the eighteenth century, when the alexipharmic or heating and sweating plan of treatment was so much in vogue on the Continent, miliary fevers of the most fatal character were among the most frequent diseases. As soon as the antiphlogistic and cooling method of treating febrile affections be- came more universally adopted, the miliary disease was but rarely observed; and it is now almost an unknown affection, except in its mildest form. By a stimulating, sweating, and heating treatment, miliary vesicles may be produced in every variety of febrile disease; and as such a plan of treatment is peculiarly apt to render even mild and manageable fevers dangerous and malignant, we may readily conceive how fatal the diseases must have been which were thus fo- mented into the miliary eruption. Sometimes, however, miliary vesicles make their appearance in acute diseases under the best regu- lated antiphlogistic treatment; and there can, I think, exist but little doubt, that an eruption of this kind appears at times as an idiopathic disease. I have seen but few instances of this kind; but one case which came under my notice within the present year, was apparently of this nature. The patient, a child, complained a few days of slight indisposition, which was followed by an eruption of innumerable red points or vesicles. On the second day they became more dis- tinctly vesicular and whitish, and continued until the fourth day before desquamation began. There was throughout the disease a constant moderate perspiration. * Stoerk, Barretta, Dissert, de Miliaris Natura, &c. as quoted by Richter. LICHEN. 529 Cazenave and Schedel observe, that" in certain cases of violent en- tero-colitis, accompanied with general debility, the miliary eruptions, which often occur at night during the paroxysms, present the next day a complete vesicular appearance, and the portion of skin which they cover, is destitute of redness, and appears as if a multitude of minute drops of limpid water had been sprinkled over its surface." The affections in which the miliary eruption is most apt to occur, are: puerperal fever; gastro-intestinal irritation or inflammation; in- flammation of the serous membranes; rheumatism; and Richter says that females affected with severe leucorrhoea are particularly liable to this affectid^ton the occurrence of febrile irritation. The occur- rence of this eruption is said to be favoured by a confined and damp atmosphere; excessive sanguineous and mucous discharges; insuffi- cient and innutritious diet; acid and other irritating substances in the alimentary canal; and intemperance. Treatment.—The attending fever must be treated according to its character and symptoms, without any regard to the miliary exan- theme. In general the febrile irritation is sthenic, and requires an antiphlogistic treatment, and cooling regimen. In short, where the eruption is symptomatic, we must prescribe for the original malady, and not for the cutaneous affection. The idiopathic cases are mild, and require little more than gentle aperients, cooling drinks, and free ventilation, without, however, exposing the patient to a cold or hu- mid air. . . The diet, of course, must be mild and unirritating; and in instances which manifest much gastric derangement, a gentle ipecacuanha emetic may be given with advantage. When the eruption recedes, and unfavourable symptoms ensue, we should endeavour to recall it to the surface by warm bathing and mild diaphoretics—such as Dover's powder; and where the arterial action is low, by the inter- nal use of carbonate of ammonia, infusion of serpentaria, camphor, and opiates. Sect. V.—Lichen. This affection is characterized by minute firm elevations or pim- ples, (papula;,) generally appearing in clusters, usually of a white colour, sometimes red, and attended with considerable itching. Sys- tematic writers describe many varieties of the disease. ' Lichen simplex.—The disease almost invariably commences with transient flushes of heat in the face; lassitude; a slightly accelerated pulse, and occasionally severe headach; weakness; painful sensations in the stomach, and general febrile irritation. The eruption consists of red and inflamed miliary pimples, attended with heat and itching. In three or four days the redness begins to fade, and on the follow- ing: day desquamation commences, which is usually completed in three or four days more, unless successive crops of papulae appear, which sometimes occurs. In the chronic variety of simple lichen, Vol. I.—67 530 LICHEN. the pimples are usually white, and but slightly or not at all inflamed. The eruption is preceded by moderate itching. The papulae are seldom very perceptible, but in passing the hand over the skin it receives the sensation of a slight roughness from the small firm ele- vations on the surface. Its course is tedious, and of uncertain dura- tion, lasting often several months. The skin becomes thickened, and at last exfoliates in large scales. Acute lichen occurs most com- monly on the face and body; the chronic, on the extremities, more especially on the back of the hands. In irritable habits it sometimes returns every summer. Persons subject to gastric pains and headach, are sometimes affected with this eruption, as if by crisis, when these affections go off. (Bateman.) Sometimes the pimples occupy the roots of the hairs of the skin. (L. pilaris.) And in this case the disease generally continues long. In some instances the papulae appear in patches or groups, well de- fined, and approaching to the circular form. (L. circumscriptus.) These spread at the same time that the central part heals and exfoli- ates, remaining, however, slightly red and scurfy. Occasionally the patches are livid, the pimples being soft and flat. (L. lividus.) These are sometimes mixed with dark red or purple maculae from sanguineous extravasation, occurring most commonly on the lower extremities of relaxed debilitated subjects. The eruption is some- times disposed into the form of a long stripe or band, extending in a spiral manner round an extremity. (L. gyratus, Biett, Cazenave.) At times the eruption consists of larger pimples than the usual size. (L. urticatus.) They are inflamed, prominent, large, confluent, " and resemble the stings of a nettle." They come out suddenly on the face or neck, particularly in young persons and females in the summer. A burning pain and considerable itching attends. They usually disappear in a short time, but often return at irregular intervals. (Cazenave and Schedel.) Infants at the breast are sub- ject to a modification of this eruption, (L. strophulus,) in which the papulae are " either redder or whiter than the skin, and attended with great itching, which is much increased by the heat of the bed." It is acute in its character, and subject to distinct exacerbations. (Cazenave.) Lichen agrius.—This is conspicuously febrile; the eruption con- sists of a multitude of vividly red miliary pimples, aggregated into large patches, seated on a diffused erythematous surface. Itching, heat, and a sense of painful tingling, greatly increased by the heat of the bed, by active exercise, and stimulating ingesta, are experienced. Morning remissions and evening exacerbations occur. The skin around the patches is generally painful and somewhat swollen. The eruption and general symptoms usually increase until about the fourth or fifth day, when small ulcerations appear on the summit of the pimples, discharging a sero-purulent fluid, which concretes into small, yellow, prominent crusts. These finally fall off, and are suc- ceeded by thin scales. The disease usually continues from twelve to LICHEN. 531 fifteen days. The itching and stinging sensation in this variety of the disease is often extremely violent. In many instances the erup- tion appears and disappears several times before it finally goes off. The skin of the affected parts generally, at last, becomes harsh, chappy, and extremely painful when rubbed. This variety may ter- minate in impetigo, a chronic pustular affection. (Bateman.) When the eruption recedes, from exposure to cold, it is apt to be followed by an increase of fever, headach, vomiting, and colic pains. Simple lichen may assume this form of the disease. L. agrius is most apt to occur in young persons of vigorous and sanguineous habits. (Caze- nave.) Lichen may also acquire a chronic character. In this case the cuticle becomes harsh, hard, full of fissures, dry, and rough, par- ticularly in the hollow of the articulations. Causes.—Lichen occurs in persons of all ages, and in both sexes. Summer and spring are the seasons most favourable to its occur- rence. High temperature, particularly the heat of the sun, is apt to excite it. Mental affections, stimulating potations habitually in- dulged in, gastro-intestinal irritation, and internal inflammations, are mentioned among its most obvious causes. Diagnosis.—Simple lichen may be distinguished from eczema by its acuminated, solid, and very prurient pimples; the eruption of eczema consisting of transparent vesicles, attended only with slight smarting pain. From scabies, lichen may be known by the distinct vesicular character of the former, and its usual location on the bends of the joints and between the fingers. The vesicles of lichen are aggregated in clusters. From prurigo, lichen is distinguished by the flat, irregular appearance of the papulae in the former, and their being usually lacerated, and covered with small blackish crusts. The itching and burning of prunigo is always extremely distressing; in simple lichen it is generally slight (Cazenave.) Lichen circum- scriptus sometimes resembles herpes circinatus; but may be known from it by the red, or more strongly inflamed state of the skin sur- rounding the margin of the latter; and the distinct papular character of the former, both in the centre and at the border of the patches; whilst in herpes the central disk is free from vesicles. Lichen ur- ticatus may be mistaken for erythema papulatum, or syphilitic lichen. The diagnosis between them consists in the large size of the erythematous patches, their pale-red colour, the almost entire absence of itching, their less prominence, and their not appearing and disappearing several times in succession. The copper colour of the papulae of syphilitic lichen, their freedom from inflammation and much itching, and their slow progress and long continuance, distinguish it from L. urticatus. From chronic eczema lichen agrius is often not easily distinguished. The presence of lichen, however, may be known by the great itching, roughness and thickening of the skin, and the appearance here and there of distinct pimples. Prognosis.—Lichen is never a dangerous, but sometimes an ex- tremely troublesome and disagreeable affection. The precursory © 532 LICHEN. fever is seldom so great as to keep the patient confined, and in the majority of instances it is wholly absent. By violent friction and scratching, and sometimes spontaneously, severe excoriations and burning pain occasionally occur, which are almost always difficult to remove. When the eruption is repelled by improper applications, or by other injurious influences, as cold, severe fever, internal in- flammations, great heat, thirst, fixed pains in the abdomen, vomiting, &c. sometimes ensue. Treatment.—In the simple variety, tepid bathing; mild aperi- ents; diluent acidulated drinks; abstinence from heating drinks, food and exercise; are all that is necessary to prescribe. Dry, irri- tating applications are improper—particularly sulphur, and the me- tallic oxydes. To relieve the severe itching and burning in the affected parts, we may apply cream, or wash the part with flaxseed tea, or some other mucilaginous fluid. When the affected parts be- come very red and irritated, attended with constant stinging pain and itching, a laxative close of calomel may be given occasionally, and fresh, unsalted butter applied. In the chronic forms of the dis- ease, alkaline and sulphurous baths, mild laxatives,* tepid bathing, at first with the water of scalded bran, " and afterwards with water rendered alkaline by adding subcarbonate of potash, in the propor- tion of half an ounce or an ounce to four or five pounds of water." Cazenave advises, in severe cases of this kind, anointing the erup- tion with one of the following ointments.t During desquamation, the internal use of the diluted sulphuric acid is often beneficial. The treatment must be more active, however, in lichen agrius. Here sanguineous evacuations, both topical and general, are often necessary in the beginning of the complaint; but when blood is drawn by topical means, it must be taken from a sound part of the skin. (Cazenave.) Low diet, laxatives, diluted nitric or sulphuric acid taken internally, laxative doses of calomel, alkaline sulphurous baths in the decline of the malady, the internal use of Fowler's solu- tion, with a gradual increase of the dose, until it produces gastric disturbance, are the means generally relied on in cases of this kind. * R.—Calomel gr. xii. Hydrarg. sulphur, nigr. gr. xxxvi.—M. Divide into 12 equal parts. S. Give one every other evening to a child of from 2 to 7 years old, with a small dose of ol. ricine on the following morning. X R.—Calomel gss. P. camph. gr. xii. Axungiae §i.—M. f. Or— R.—Protoioduret hydrarg. gr. xii. toQi. Axungiae §i.—M. f. ?*S ECZEMA. 533 Sect. VI.—Eczema. Eczema is a vesicular eruption, which occurs both in an acute and chronic form. Cazenave and Schedel divide acute eczema into three varieties, namely, E. simplex, E. rubrum, and E. impetiginodes. 1. E. simplex.—The eruption consists of innumerable small, closely approximated, transparent vesicles, without any surrounding inflammation, distributed over a greater or less extent of the surface —the skin every where retaining its natural colour. No premonitory symptoms, but only a slight itching, precede the eruption. The fluid in the vesicles soon becomes opaque, and after a short period is ab- sorbed; the vesicles then shrivel, and the cuticle desquamates slowly. It never spontaneously gives rise to inflamed surfaces. This eruption is usually local, or confined to certain parts—commonly the arms and between the fingers, and being attended with severe pruritus, may be mistaken for the itch. Heating and irritating applications to the skin often produce this affection. " It often appears between the fingers of women in child-bed;" and in persons who are much exposed to the heat of a fire. It is sometimes associated with itch, and appears to be excited by the irritating remedies usually employed for the cure of that affection. 2. Eczema rubrum.—Heat,stiffness, and some tingling in the skin, precede the eruption in this variety. The affected surface is inflamed and vividly red, covered with very minute acuminated pimples, of a shining white or pearly hue. After some time, vesicles of the size of a pin's head, surrounded with distinct red areolae, appear on the af- fected parts. In the course of six or seven days, the contained fluid is absorbed, the vesicles shrivel and desquamate, leaving a pale red surface, sprinkled with minute rounded papulae, each rising from a small whitish disk. In some instances the cutaneous inflammation increases, and continues beyond its ordinary duration; the vesicles be- come confluent, break, and discharge an irritating fluid, which causes superficial excoriations; and at last, concrete into large, thin, pliant scales, leaving inflamed surfaces on falling off. 3. Eczema impetiginodes.—Violent inflammation, swelling of the affected parts, and vesicles generally congregated or confluent, filled with a sero-purulent fluid, are the principal characteristics of this variety of the disease. These purulent vesicles soon break, and the fluid concretes into soft, yellowish, and often extensive scales, or thin crusts. When these fall off, they leave red surfaces, exuding a red- dish fluid, which dries into thin laminae. The eruption is commonly confined to a particular part, or even a single spot. Occasionally, however, it occurs over the whole body, and is attended with con- siderable fever. The disease may continue from ten to twenty days, and upwards. The vesicles are generally transparent at first, and be- come pustular afterwards. This variety also sometimes assumes a chronic character,resembling then the chronic stateof eczema rubrum. 534 ECZEMA. 4. Chronic eczema.—When acute eczema is very severe, it often terminates in chronic excoriations and fissures of the skin on differ- ent parts of the body, particularly in the bends of the knees and elbows, and about the axillae. The parts thus irritated and inflamed, exude an abundance of serous fluid, which causes the linen to adhere to them. In this state it usually remains for several months, the dis- charge continuing undiminished. In some instances, the exuded se- rum dries into soft, yellowish, and thin crusts, leaving an inflamed and nearly dry surface when they fall off. " These crusts form at greater intervals; they become drier, and the disease seems on the point of disappearing, when on a sudden, and without any assignable cause, the inflammation acquires greater intensity." New vesicles arise, which, like the former, soon break and discharge their fluid; "and the affection goes through the same course, and the disease may thus last for years." (Cazenave.) Sometimes, the thickened, red, fissured skin, remains dry, and the crusts are drier, more firmly attached, and of a brownish yellow hue, leaving but a slightly red surface when they separate. Occasionally, indeed, the skin for a long time remains vividly red, cracked, with dry scales of altered cuticle thinly scattered over the surface. Chronic eczema commences on a limited portion of the skin, often not above a few inches in diameter, and spreads afterwards over a greater or less extent of the surface. The itching is always very great, and returns by spells, causing an irresistible desire to scratch. The parts furnished with hair, the region of the pubis, the arm-pits, groin, scrotum, pudendum, and the bends of the joints, are most apt to become the seat of eczema, although every part of the body may become affected with it. Causes.—Though not contagious, yet instances do occasionally occur, in which this disease is communicated from one to another by protracted contact. (Biett, Cazenave.) It occurs more frequently in women than in men, and in the warm than the cold seasons. Its general cause is unknown. It may be excited, by direct irritating applications to the skin, as a blister, sinapisms, turpentine, valerian root, the rays of the sun,* dry frictions, and irritating ointments, lime, and sugar.t The use of mercury, when long continued, sometimes produces a very severe variety of eczema. Diagnosis.—Simple eczema often greatly resembles itch. They may be distinguished by the following circumstances. In eczema, the vesicles are flat or rounded; in itch, pointed; in the former,they are nearly or entirely in contact with each other; in the latter, they are single and considerably separated. The itching of eczema is at- * The prickly-heat or heat-spots are classed with this variety of eruptions. (Willan.) | Persons who are in the habit of handling or working in sugar are liable to an eruption of this kind on the hands, called the grocers* itch. (Bateman.) And bricklayers are subject to a similar affection from the irritation of lime. ECZEMA. 535 tended with smarting pain; in itch, the pruritus " is rather agreeable than painful." The impetiginode variety of eczema has been confounded with impetigo. The former, however, occupies large spaces, the latter usually small ones. The eruption in impetigo is strictly pustular from the beginning. In eczema impetiginodes, it is vesicular at first, the vesicles being generally transparent, and never contain genuine pus, as they do in impetigo. In the latter, desiccation gives rise to thick, yellowish, uneven scabs; in eczema, only thin pliant scales are formed. Vesicles of eczema rubrum surround the latter, but they never appear in impetigo. Chronic eczema is very liable to be confounded with lichen and psoriasis. . Lichen agrius, the variety most apt to be mistaken for chronic eczema, differs from this affection, in the thick, small, and yellow appearance of the scales or scabs, and the papular appear- ance of the surface which they leave on falling off; whereas, the sur- faces left by the separation of the thin lamina in eczema, are smooth, red, often shining, and generally slightly excoriated. In lichen, small hard papillae may be seen around the eruption; in eczema, vesicles only appear in the neighbourhood of the eruption. Treatment.—Diluents, acidulated with sulphuric, or nitric acid; a light and simple diet; occasional tepid bathing; gentle laxatives; and where the eruption is extensive, alkaline and sulphurous baths,* with some of the milder vegetable tonics, such as infusions of cin- chona, serpentaria, or colomba when languor or debility exists, are the principal useful measures in this variety of the complaint. When the eruption continues long, advantage may be obtained from rub- bing the affected parts with sulphur ointment. In eczema rubrum and impetiginodes, frequent bathing, or emol- lient fomentations of the affected parts, will generally moderate "very considerably the itching pain and tenderness of the eruption.t Emol- lient poultices also often answer well as a palliative application. After exfoliation, the following ointment may be beneficially applied to the tender and half-excoriated surfacej by means of linen rollers renewed twice daily. Mild laxatives should be regularly given; and a simple, unirritating diet, as well as total abstinence from all * The alkaline bath is made by dissolving five or six ounces, or more, of the subcarbonate of potash or soda in a bath. The sulphurous bath is made by add- ing about four ounces of sulphuret of potash to a bath. (Cazenave.) f The French are in the habit of using a decoction of bran, or the water of scalded bran, for this purpose. Cazenave and Schedel recommend cataplasms made of potatoes and some emollient decoction. X R.—Emplast. plumbi %\\. Cerae flavae ^ss. Olei amydal. dulc. ^iss.—Melt the plaster with the wax, then add the oil, and stir the mixture until it has entirely cooled. This ointment is particu- larly recommended by Dr. Pearson.—See Raleman,s Synopsis, &c. p. 12. 536 ECZEMA. kinds of stimulating drinks, enjoined. It will also be useful to ad- minister refrigerant diaphoretics, such as sweet spirits of nitre, small portions of nitrate of potash with tart, emetic, spiritus mindereri, and to allay nervous irritation and procure rest at night, full doses of Dover's powder with a few grains of calomel in the evening. The diluted mineral acids with tonic bitter infusions will at times be proper during the subsidence of the disease. All kinds of irritating applications must be avoided. When the exciting cause is obvious, and of such a nature as to enable us to remove it, the first step in the treatment must of course be to obviate its influence. In chronic eczema, emollient baths of about the temperature of 90°Fahr.; the internal use of nitric or sulphuric acid; occasional laxatives; alkaline solutions internally, and when the itching is great, externally,* are among the principal remedies in this form of the disease. One or two of Plummer's pillst given tvvice daily, have been found very useful in chronic eczema. Benefit may also be derived from laxative doses of calomel and pulvis antimonialis, with an occasional dose of sulphate of magnesia or soda. Sulphur- ous waters, employed both externally and internally, will, in gene- raf*, contribute materially towards the removal of the disease. In- fusions of sarsaparilla, chimaphila, or of the slippery-elm bark, with small portions of antimony, may also be usefully employed. In a very severe and inveterate case of chronic eczema, 1 prescribed the following pills, in conjunction with sarsaparilla syrup, with complete success.J In the dry, scaly, cracked form of local eczema, "as it occurs in the hands," Cazenave recommends frictions on the part, with an ointment made by mixing half a drachm of proto-nitrate of mercury with an ounce of lard; or of twenty grains of proto-ioduret of mercury rubbed up with an ounce of axunge. I have known a case of this kind cured by the following application,§ first recom- * " Half a drachm of the subcarbonate of potash dissolved in a pint of infusion of chicory may be given internally." Washing the affected parts with a solu- tion of the subcarbonate of potash or soda, before going to bed, will generally afford much relief. (Cazenave.) t R__Calomel. Antimon. sulph. praecipitat. aa ^ii. Pulv. g. guaiac. giv. Sapo. venet. gii. Mf. pi. aa gr. iii. X R.—Muriat. hydrar. corosiv. gr. iii. G. opii. gr. x. G. camphor, gr. xx. Conserv. rosar. q. s.—M. Divide into 40 pills. Take one every morning, noon, and evening. § R—Axunge §viii. Melt it, then gradually add, ?iilric acid §i. and stii until it is cold. ERYTHEMA. 537 mended, I believe, by Alyon. (Essai sur les Proprietis Med. de I'Oxygene.) Washing the affected parts with an infusion of stramonium leaves, or of solanum nigrum, or hyoscyamus, will generally greatly allay the itching and painful irritation. When the eruption is confined to a limited surface, solutions of borax, lime-water and milk, or an ointment made by mixing half a drachm of calomel with an ounce of lard, may be occasionally applied with benefit. The best local ap- plication, according to my own experience, however, is stramonium ointment intimately mixed with a portion of calomel, in the propor- tion of thirty grains of the latter to an ounce of the former. The tincture of cantharides is sometimes very efficacious in obstinate cases of this affection. Cazenave states that it is particularly useful in the eczema of women.* Arsenic also has been used with complete success in inveterate instances of chronic eczema. (Biett, Cazenave.) The Asiatic pills appear to be the best arsenical preparation in this affection. One of these should be taken daily, and continued for several months. I have employed Fowler's solution in several cases with marked advantage. Sect. VII.—Erythema. The term erythema, is applied by Willan, and other late writers, to a cutaneous affection, characterized by a slight superficial irregu- larly circumscribed redness of some portion of the skin, attended with symptoms of constitutional disorder. It is most commonly seated on the face, breast, and extremities, and continues usually from one to two weeks. It appears generally as a symptomatic af- fection—although in many instances it occurs without being pre- ceded by any obvious constitutional symptoms. Superficial spots of a vividly red colour, variable in size, and attended usually with very slight heat and pain, come out on a greater or less extent of the surface. When these spots are pressed with the finger, the redness disappears for a moment, as in erysipelas. In some instances, not the slightest tumefaction attends; but in others, the spots become swollen and firm to the touch. Sometimes the bright red patches are irregularly rounded, and present on their first appearance a slightly elevated rough or papulated surface. In a few days the redness becomes more vivid, and afterwards changes to a violet hue, particularly on the central parts of the patches. The slight swelling * Cantharides have been successfully employed in various chronic cutaneous affections. Keir relates several very obstinate instances of impetiginode affections which yielded to a protracted course of this remedy, (VoigtePs Arzneimittell, bd. ii. Abth. ii. s. 15.) Home also gave it successfully in herpatic affections, (Clini- cal Experiments, &c.) Tilenius, (iiber die Flechtenurt. Hautauschl. 1802,) and Simons, (Med. Comment, vol. i.) relate instances ef its successful employment in similar diseases. Vol. I.—68 538 ERYTHEMA. subsides in the course of the second day, but the redness continues from about ten to fourteen days. This variety of the disease (the E. papulation of Willan) is most frequently met with in females and young persons, and is usually seated on the neck, breast, and arms. It is sometimes attended with much general disorder—such as anorexia; a small and frequent pulse; great depression of strength and spirits; and acute pain in the limbs. In most instances, how- ever, the constitutional symptoms are slight. (Bateman.) In some cases "small slightly elevated tumours are interspersed through the patches," which continue six or seven days before they disappear— the redness going on for about a week longer. (E. tuberculatum.) This eruption frequently appears also in the form of red oval spots, usually seated on the anterior part of the legs, and sometimes, though rarely, on other parts—as the chin and arms. The spots become elevated towards the centre,and are firm and painful to the touch, presenting the appearance of slight nodes when seated on the tibia. These protuberances rise slowly, and subside about the eighth or ninth day, at the same time that their colour becomes bluish, as from a bruise. This variety of the disease is preceded for four or five days by moderate fever, general uneasiness, and depression of strength. Bateman says that it seems to occur only in females; but Cazenave and Schedel state that it is met with also " in infants, and in young persons of a weak constitution and lymphatic tempera- ment." This variety constitutes the E. nodosum of Willan. The erythematous spots which sometimes occur in acute diseases as symp- tomatic eruptions, (E.fugax) are usually of short duration, and re- semble the redness produced by pressure or friction. They occur also in chronic affections, " especially those in which the primae viae are deranged." Causes.—Erythema may be produced by the direct action of irri- tating agents on the skin, such as the direct rays of the sun; acrid secretions or discharges remaining long in contact with the skin; and by the chafing of two contiguous surfaces, as between the breasts, in the arm-pits, groin, and on the buttocks and internal parts of the thighs from riding on horseback. It occurs symptomatically from intestinal irritation, dentition, menstrual irregularities, particularly about the decline of the menses, from irritation in the stomach, and in almost every form of acute disease. It is sometimes associated in oedema, or anasarca of the legs. Diagnosis.—From erysipefas, erythema is distinguished by the limited extent of the spots; the absence of pain, of vesication, and of tumefaction; and the mild nature of the disease. From roseola it differs in its vivid redness, and in the less distinctly defined circum- ference of its spots or patches. The spots of roseola are never raised above the surrounding skin; those of erythema nodosum are. Ery- thema papulatum may be known from urticaria by the greater ele- vation of the latter, and the great itching which always attends, as well as by its " irregular and often rapid course." The absence of ROSEOLA. 539 itching in erythema distinguishes it also from lichen urticatus. (Ca- zenave.) Treatment.—Light diet, gentle diaphoretics, the internal use of the mineral acids, laxatives, warm baths, tepid ablutions, and sooth- ing applications when it occurs from the friction of surfaces, such as aqueous solutions of borax, opium, acetate of lead, or pulverized starch, or the powder of lycopadium, comprise all that is necessary in idiopathic erythema.* Sect. VIII.—Roseola. This affection consists of rose-coloured spots, of various forms, without swelling or elevation of the skin or papulae, and is usually preceded and accompanied by febrile symptoms. These efflor- escences may occur over the whole surface of the body, but they are usually confined to one or more parts. lis course varies in dura- tion from one to about six or seven days. Sometimes the rose-red spots are nearly circular, contiguous to each other, and not above three or four lines in diameter. They are usually connected with disorder of the stomach and bowels, and occur almost exclusively in infants, and they seldom last longer than thirty-six hours. During dentition these spots are apt to assume an irregular and nearly con- fluent appearance, and generally succeed violent symptoms of gastro- intestinal disorder, such as vomiting, diarrhoea, and fever. There is a variety of this^ eruption which has been mistaken for measles, and which is most apt to occur in children during summer. (R. sestiva.) It commences with chills, languor, headach, followed by febrile reaction, and occasionally delirium, and even convulsions. The skin is hot and dry, the bowels are constipated or affected with diarrhoea, and the appetite wholly depressed. From the third to the seventh day after the commencement of these symptoms, the erup- tion makes its appearance, first on the face and neck, and then gra- dually spreads over a greater or'less extent of the surface of the body. The spots are usually from one to three lines in diameter, resem- bling the spots produced by touching bibulous paper with the point of a pen dipped in red ink. When the eruption is very copious, the spots run into each other on some parts of the body, but the roseolous points may still be distinguished on the red surface. These spots are not in the slightest degree elevated, yet when the patient has been kept too warm, or when heating diaphoretics are used, a papular eruption is apt to appear along with the roseolous spots. The eruption is attended with troublesome itching, and the febrile * To relieve the inflammation and tenderness produced by chafing, the follow- ing ointment, applied by strips of soft linen, is often promptly effectual: R.—Ungt. stramonii %i. Pulv. lithargyri gi. Pub. opii gss.—M. 540 PURPURA. irritation continues until it disappears with the eruption. It is often attended with sore throat, or painful deglutition, but not with coryza, inflamed eyes, and cough, like measles. The spots may continue from three to ten days; they disappear without desquamation. Oc- casionally a second eruption occurs after the first has gone off. In some rare cases, the rosy spots assume an annular shape, the central parts retaining the natural colour of the skin. (R. annulaia. Willan.) Roseola occurs most frequently in women and children, and is not contagious. It occasionally prevails epidemically, and some- times precedes the eruption of small-pox, or it follows the vaccine affection. Dentition, and a draught of cold water when the body is heated by exercise, may give rise to this eruption; and it is often associated with gastric disorder, particularly in children. Diagnosis.—Measles and scarlet fever, are the affections with which roseola is most liable to be confounded. The more distinct catarrhal character of measles, the irregular semilunar grouping of its small red points, and the vivid redness of its eruption; contrast- ed with the larger, more circular, well defined, and rose red spots of roseola, will generally enable us, without difficulty, to form a cor- rect diagnosis. The small vesicular elevations, the irregularly dif- fused raspberry efflorescence, and the tumefaction of scarlatina, are usually sufficient to distinguish this affection from roseola. Roseola is not contagious; measles and scarlatina are. Prognosis.—This disease is almost always wholly free from dan- ger. Heim,* Selle,t and Formey,^ however, mention the occurrence of very violent and fatal epidemics of this kind. But in these the eruption was probably purely symptomatic of typhous fever. Hilde- brandt refers to an exantheme, somewhat similar to this one, as a very constant, though transient, symptom, in the stage of excite- ment of contagious typhus. Treatment.—Rest, mild aperients, acidulated cooling diluents, a simple and unirritating diet, an equable and moderate temperature; and where the temperature of the. skin is elevated, refrigerant dia- phoretics, are, in general, all that is required in the treatment of this affection. When internal inflammations occur, a more vigorous and appropriate course will be demanded. Sect. IX.—Purpura. Hemorrhoza Pelechialis, Ecchymome, Hemacelenose. This affection is characterized by spots or patches of a vivid red, inclining sometimes to a purple hue, varying in size from a line to * Bemerk, iiber die Verschieden. des Sharlachs, der Roethel und der Masern. X' Neue Beitrage zur natur-und Arzneiwissenschaft, tom. i. X Topographie von Berlin, Richter, Specielle Therapie, Bd. ii. p. 524. PURPURA. 541 several inches in diameter, and retaining their colour under pressure. These maculae appear often without any perceptiblefebrile phenomena whatever; but they occur also in the latter stage of malignant fevers, (pe/echise,) and in this case are always of the most fatal import. W illan has divided purpura into five species: purpura simplex; purpura hsemorrhogica; purpura urticans; purpura senilis; and purpuru contagiosa. Simple purpura consists in small bright red patches, appearing usually on the extremities in a successive manner, preceded com- monly with slight restlessness, nausea, headach, languor, and want of appetite, but without any obvious irritation of the circulatory system. The duration of this affection is almost always tedious, and varies from a few weeks to many months. The individual spots, however, do not often continue more than seven or eight days—the whole course of the malady being made up either by a continuous succes- sion of the eruption, or a succession of eruptions, with short inter- vening periods. This variety of the disease occurs usually in young subjects, and appears equally liable to attack vigorous, sanguineous, and robust, as well as feeble, relaxed, and delicate individuals. It is said to appear more frequently during warm and dry weather, than in the cold seasons. Its diagnosis is not difficult. The persistence of the redness when pressed with the finger, is alone sufficient to distin- guish it from all other similar affections. Simple purpura is always a mild affection, and though sometimes very prolonged in its course, can never be.regarded as dangerous. P. hsemorrhogica.—The variety of purpura, however, which has attracted the most attention, and which indeed is always a very seri- ous and alarming affection, is the purpura hsemorrhagica—or mor- bus maculosus hsemorrhagicus of Werlholf. The spots in this va- riety are generally numerous, and of a dark-red colour, with here and there irregular livid patches, resembling recent bruises. They usu- ally appear first on the legs, then on the arms, and lastly on the body; the hands almost invariably remaining free from them. In some instances the cuticle over these maculae becomes slightly elevated, with a small portion of bloody serum underneath.* These spots occur also on the mucous surfaces, particularly in the mouth, nostrils, rectum, or vagina, giving rise to haemorrhages, sometimes so copious as to cause speedy death. In general, however, the haemorrhage is moderate, returning at intervals, and either ceases spontaneously, or recurs again and again until the system is exhausted, and a fatal ter- mination occurs; sometimes a slight, but uninterrupted, discharge takes place. The constitutional symptoms vary exceedingly in this affection. Some cases commence with wandering and vague pains, lassitude, restlessness, and exhaustion; others are not preceded by any symptoms of general indisposition. In general, however, the disease, * I. G. Arcel, (C. Zetterstrom) Diss, de Haemorrhoea. Upsal, 1797. 542 PURPURA. when once developed, is accompanied with a state of depression and languor; yet in relation to the activity of thepulse,the greatest di- versity occurs in different cases. In some instances it is feeble, soft, and moderately full; in others it is contracted, firm, and very fre- quent; and in others again, active, full, and resisting. The skin is sometimes above the natural temperature;* though generally it is cool and pale. Cough, pain in the chest, and slight oppression of respiration, frequently precede and accompany the cutaneous and haemorrhagic affections. Dr. Fairbairn relates a case attended with deep-seated pain in the left breast, increased on coughing and deep inspiration, laborious breathing, and flushed countenance. Dark, venous blood oozed from the gums, cavity of the mouth, and appa- rently from the mucous membrane of the bronchiae, and numerous petechiae or purple spots appeared on the arms, neck, and trunk.t Uneasiness in the stomach, with abdominal pain, or tension and weight in the hypochondria, sometimes precede the appearance of the spots. When the disease becomes protracted, more or less ana- sarcous tumefaction of the legs and face, emaciation, and great weak- ness and languor, supervene. The duration of this malady is as va- rious as the general phenomena which accompany it. It may termi- nate either in health or in death, within a few days from its com- mencement, or run a tedious course of many months. The fatal ter- mination of this affection is frequently the immediate consequence of profuse haemorrhage from some internal organ. Cazenave states that he has "seen patients suddenly expire from copious haemoptysis, as well as from haematenesis and intestinal haemorrhage." The spots or maculae are caused by the extravasation of blood under the cuticle. Concerning the etiology and pathological character of this re- markable affection, we know, as yet, but little that is satisfactory. Dr. Parry regarded the disease as being decidedly phlogistic, whilst most other writers ascribe to it an opposite character. It is certain, that notwithstanding the extraordinary tendency to haemorrhage— apparently of the passive kind—the blood drawn with the lancet sometimes coagulates strongly, and exhibits a sizy, and even a cup- ped and buffy surface.J It is equally ascertained that extensive in- ternal inflammations are sometimes connected with this malady. In the case reported by Dr. Chambers, (Med. and Phys. Jour. Nov. 1826,) "the convolutions of the small intestines were found agglu- tinated by adhesive inflammation, and the whole arachnoid mem- brane on the upper part of both hemispheres was covered with lamina of coagulated lymph." More commonly, however, the blood taken * See Dr. Gardiner's case—Edinburg Med. Chir. Transact, vol. i. p. 671. Also, Dr. Fairbairn's case, quoted below. X Transact. Med. Chir. Society of Edinburg, vol. ii. art. 1. X Dr. Stocker, Pathological Observations, &c. part I. p. 36. Parry's Posthu- mous Works, vol. i. p. 220. See also Dr. Chambers' case__Med. Chir. Rev. Jan. 1827, p. 201. PURPURA. 543 by venesection presents none of the appearances indicative of a phlo- gistic condition. "In many persons who were examined after death in the hospital St. Louis," says Cazenave, " the blood was found in a state of remarkable fluidity." In Dr. Fairbairn's case, the blood coagulated " into a soft and tremulous mass," and in the case report- ed by Dr. Gardiner, the first blood drawn coagulated imperfectly, and on the following day resembled a tremulous jelly, with a green- ish surface interspersed with brownish spots. What was discharged afterwards " was more like turbid lymph, or a fluid in which some reddish colouring matter was suspended." In the majority of instances, marks of violent venous congestion,* with copious extravasation of bloody serum or dark liquid blood into the internal cavities, are detected on post mortem examination. Petechae, too, are often met with on the internal surfaces, particu- larly on the mucous membrane of the lungs, intestines, stomach, (Fairbairn, loc. cit.) and fauces. In some instances*almost the whole capillary system takes on the haemorrhagic action—every structure, whether membranous or parenchymatous, presenting marks of san- guineous extravasation. Under all this perplexing contrariety of phenomena, our reason- ings and conclusions respecting the fundamental pathological charac- ter of this affection, must necessarily be vague and unsatisfactory. That it is not essentially an inflammatory disease, though often connected with local inflammation and an active state of the circula- tion, appears, 1 think, extremely probable. It is indeed true, that in some of the most violent forms of inflammatory fever, colliqua- tive haemorrhages and subcutaneous extravasations of blood occur; but these do not supervene until the general powers are prostrated, or a state of collapse is induced by the previous excessive excitement. In purpura, however, the petechias and sanguineous discharges are sometimes among the first signs of indisposition; and are but very rarely preceded by symptoms of strong vascular or phlogistic action. Dr. Stocker thinks that this affection is attended with an altered and unhealthy state of the blood, "either from want of due preparation of the fluid at the two chief sources of supply, and of the subsequent changes these fluids should undergo in their passage through the pulmonary, sanguiferous, and hepatic systems, or from the injurious effects of diseased functions in the organs of sanguifica- tion, "t That a dyscracy of the blood exists in this disease, is indeed not at all improbable; but whether this condition of the blood has a direct and principal agency in the production of the characteristic phenomena petechias and haemorrhage; or whether it is only one of * The lungs are sometimes greatly engorged with sanguineous extravasation and congestion. M. Biett saw an instance of violent venous congestion of the tongue. It was of a deep livid colour, and double its natural size. (Cazenave and Schedel.) X Loco cit. p. 40. 544 PURPURA. the ultimate consequences of the primary and essential disease, is altogether uncertain. To me it seems probable that this affection has a considerable latent period before it manifests itself by external symptoms; that primary disorder of the assimilating functions de- ranges the healthy constitution of the blood; and finally, that the blood thus deteriorated or changed, being no longer possessed of its healthy relations with the organic sensibility of the capillary ves- sels, causes these to suffer its ready transmission and extravasation. Treatment.—The uncertainty which exists in relation to the pathology of this disease, leaves us of course in an equally unsettled state with regard to the principles of its remediate management The most opposite plans of treatment have been recommended, and practised too, with occasional success. It would seem even that the existing symptoms are often a very fallacious guide; for in some cases marked with all the usual symptoms of general debility, relaxa- tion, and asthenia? the use of tonic and other invigorating means have almost immediately aggravated the disease. Nevertheless, where the disease occurs in old persons or .children, enfeebled by previous diseases, privations, or other debilitating influences, a mode- rate tonic and exciting plan of treatment, with an invigorating regi- men, has been found most beneficial. Decoctions of cinchona, ser- pentaria, or rathany; the ferruginous preparations; mineral acids, particularly the sulphuric; wine, and a nourishing diet, may be em- ployed in cases of this kind. The only instance of this disease which has come under my notice, was in a child about seven years old. In this case I employed the nitrate of silver, in quarter grain doses every six hours, Together with from fifteen to twenty drops of the spirit of turpentine, with complete success. The case continued for nearly three weeks before it yielded to this treatment. When the disease appears in adults of good and sanguineous con- stitutions, and who have not been previously subjected to the influ- ence of enervating causes, tonics and exciting remedies almost inva- riably do great mischief. In all instances in which there are mani- festations of strong visceral congestions, or of inflammation; where there is pain in the chest, in the epigastrium, hypochondria, or the abdomen; where there are evidences of intestinal irritation, or con- stipation exists; where the pulse is firm, corded, or tense, antiphlo- gistic measures should be adopted. Bleeding is recommended by Parry, and cases have been reported illustrative of its occasional be- neficial effects. A case is reported as having occurred in Bartholo- mew's Hospital, which strikingly illustrates the occasional usefulness of blood-letting in this affection. The whole surface of the body was sprinkled over with purple spots. The gums were spongy, livid, and bloody. "The whole tongue also, was livid, and half of it presented the appearance of a large, black, bleeding fungus, shoot- ing from its surface." Nothing but blood passed by stool. The pa- tient nevertheless felt strong, and had a good appetite. Dr. Latham drew fifteen ounces of blood, which was very buffy, enjoined water PURPURA. 545 gruel, and administered mercurial purges. The patient under this management gradually recovered.' Where the disease is attended with an active state of the circulation, or with symptoms of visceral congestion or inflammation, bleeding may be practised with a prospect of advantage. It is a measure, how- ever, which requires cautious employment even where it seems to be most clearly indicated; for the natural tendency of the disease to exhaustion and prostration is always" great, and may readily be inju- riously promoted by incautious abstractions of blood. Whatever may be thought of blood-letting, almost all writers agree in recommending purgatives in this affection. Dr. Harty states, that after he had failed in one case by tonic remedies and a nour- ishing diet, he resorted to the free administration of purgatives in upwards of a dozen cases, and he avers, with uniform success. (Bate- man.) He gave active doses of calomel and jalap daily. Of late years the oil of turpentine, in purgative doses, has been strongly recommended as a remedy in purpura. Dr. Whitlock Nicholl has reported three cases in which this article was administered with the most satisfactory result.t To a child only two years old he gave half a drachm of the oil with some syrup and water, thrice daily, for ten days in succession. Under this remedy, the disease, though very vio- lent, gradually yielded. Cinchona was, at the same time, freely used. Dr. E. Thompson also gave small doses of turpentine and castor oil with complete success.^ Dr. Belcher used turpentine enemata, with manifest advantage.§ The turpentine with castor oil generally causes large, unnatural, and very fetid alvine discharges; and if the system is, at the same time, supported by tonic infusions, generous wine, and the mineral acids, nothing need be apprehended from the ex- hausting effects of daily purging with this mixture. According to the report of Cazenave and Schedel, the treatment usually adopted in the management of this disease by M. Biett, consists in the employment of acidulated drinks and laxatives; and in cases attended with much feebleness and exhaustion, the extract of rathany, (in doses varying from a scruple to a drachm daily,) mixed with ice. This treatment is also recommended by other emi- nent French practitioners. (Dr. Brachet, of Lyons.)(| Local applications have been recommended to restrain the haemor- rhages, but these rarely afford any other than very temporary advan- tages. Upon the whole, therefore, moderate blood-letting, where there are strong congestions, or an active pulse; purgatives freely and almost daily employed, together with cinchona, rathany, tinct. cinnamon,^ wine, beverages acidulated with sulphuric acid, and a * Med. Chir. Rev. May, 1828. X Lond. Med. Repository, July, 1821—Ibid. No. VI. X Ibid. No. CX1X. § Med. and Phys. Jour. March, 1825. || Cazenave, &c. Synopsis, p. 379. Tf Jahn. Klinik der Chron. Krank. Bd. p. 308. VTOL. I.—69 546 HEMORRHAGES. nourishing diet, constitute the means which experience has found most apt to afford relief in this affection. Advantage might perhaps be obtained from bathing the body in a decoction of oak bark or cin- chona, or water strongly impregnated with salt. CHAPTER XIX. VASCULAR IRRITATIONS WITH A PLOW OP BLOOD. Hsemorrhages. Spontaneous Hemorrhage may be defined a disordered state of the vital properties of a greater or less extent of the capillary system, manifesting itself by sanguineous effusion, or extravasation.* It was formerly supposed that haemorrhages depend invariably on rupture of a blood-vessel; and this opinion is, indeed, still entertained by some pathologists. Dr. Gregory seems to take it for granted that actual rupture of a vessel takes place in all haemorrhagic effusions.t That this may sometimes occur, cannot be doubted; but this is proba- bly so seldom the case, as to form but a very limited exception to the general fact, that the effusions of this kind depend on a sort of sanguineous exudation, without rupture, or structural lesion of the vessels. In what manner, or through what particular openings, the blood is suffered to escape from its proper vessels, is, however, still a matter of conjecture, or at best of uncertainty. According to Bichat, the blood is discharged through the exhalents; and Reil supposes that it transudes through the coats of the vascular extremities, (per dia- psedesin,) from deficient vital power in these structures, just as we sometimes find the bile percolated through the cystic coats on post mortem examination, or by what Dutrochete calls exosmos, through the agency of animal galvanism. When we take into view the results of some late physiological experiments, which go to show that the veins imbibe fluids into their cavities apparently through the insen- sible pores of their coats; it does not appear extravagant to suppose, that, under particular circumstances, they may also give exit to their contents through the same channels. It is nevertheless most probable that the effusion occurs, (per anastomosin,) through the exhalents, in the manner so ingeniously explained by Bichat. In consequence of a morbid change in the activity of the sanguineous capillaries, as well as in the specific sensibility of the serous exhalents, the blood * Bichat, General Anatomy, vol. ii. Reil, Fieberlehre. Bd. iii. p. 23. f Elements of the Theory and Practice of Medicine, vol. i. p. 517. Second American edition. hemorrhages. 547 passes from the former into the latter, and by these is suffered to escape externally. Whatever doubts and exceptions may have been expressed by some recent physiologists, with regard to the agency of what this eminent writer terms organic sensibility in the deve- lopment of diseases, there is much foundation for believing that this pathological principle lies at the root of many of the morbid phenomena of the capillary system. It would be foreign, however, to the scope of this work, to enter into a particular discussion on this head. Those who may desire to obtain a full view of the facts and arguments that may be adduced in support of this pathology of haemorrhages, may consult the chapters on the capillary and exhalent systems in Bichat's General Anatomy. Pathologists have divided haemorrhages into active and passive. A haemorrhage is said to be active when there is a preternatural flow of blood to the part, attended with an increased vascular excite- ment In many cases, the whole circulatory system is in a state of increased activity; but the local vascular excitement often approaches, and indeed actually rises to the grade of inflammation, as in the spitting of blood in pneumonia, or the sanguineous discharges in dysentery. The local haemorrhagic irritation is, however, not always accompanied with an increased momentum of the general circulation. On the contrary, strong local determinations, and an active haemor- rhagic excitement, often exist in an organ, whilst the activity of the heart and arteries is depressed, and the general powers of the system languid. Thus active haemoptysis and uterine haemorrhage often occur in persons of weak and irritable habits, with a small, weak, and frequent pulse. Active haemorrhages occur most frequently in young, plethoric, and irritable persons, and in those who are constitutionally predis- posed to strong irregular determinations of the blood to particular organs, as the head, the lungs, or the abdoniinal viscera. They occur in inflammatory fevers, either as accidental or critical evacuations; and in this case, they are always to be regarded as favourable. In many instances, the eruption of the blood is preceded by various premonitory symptoms; but in others, the haemorrhage comes on suddenly without any manifestations of its approach whatever. Among the symptoms which announce the approach of active haemor- rhages, may be mentioned, a full, frequent, rebounding (dicrotus; bis feriens) pulse; alternate flushes of heat and chills; redness, tension, and fulness of the skin; increased sensibility of the sensorial organs; restlessness; anxiety; watchfulness; slight aberrations of the mind; a feeling of heaviness, pressure, heat, and pain in the part; and in some instances, a turgid state of the veins, redness, and swelling in. external parts remote from the organ from which the blood is about to flow. Haemorrhages are called passive when there is neither sanguineous congestion, nor a sense of heat, and fulness, but a decreased instead of an increased vascular activity, both of the general system and of the 548 hemorrhages. part from which the haemorrhage occurs—the exhalents suffering the blood to escape passively from want of vital activity to resist its en- trance and transmission. Some have contended that all haemorrhages are necessarily active; that the blood is always thrown out by an action of the exhalents, and not merely forced through them, as through passive tubes by the vis a tergo. This may be true; and yet when we find some chronic haemorrhages, connected with great feebleness and relaxa- tion, speedily arrested by remedies which all physicians are accus- tomed to regard as the most energetic means we have for stimulat- ing or exciting these very vessels to increased activity, we cannot be much out of the way if we call such discharges passive. In that variety of chronic haemorrhage which occurs in relaxed and debili- tated females at the critical period of life, we possess no medicine which so promptly and safely arrests the discharge, as small doses of aloes and savin in combination—the very remedies, too, which we often find most successful to excite the menstrual evacuation; in other words, the uterine vessels. This variety of haemorrhage depends either on mere relaxation and inactivity of the vessels, without any morbid changes in the constitution of the blood, in consequence of previous diseases, excess- ive discharges of all kinds, and other exhausting influences; or it is connected, and probably in a great degree dependent on a thin, watery, or dissolved state of the blood, and therefore incapable of communicating healthy impressions and activity to the general and capillary systems of vessels. This state is always attended with a variety of symptoms besides the haemorrhage, indicative of a relax- ed, exhausted, and sometimes irritable condition of the system.* Of this kind of haemorrhage (passive) are those which occur in some chronic affections, attended with great relaxation, exhaustion, and morbid irritability, such as scurvy; and in the stage of collapse of malignant and other typhous forms of febrile diseases. In some instances, the haemorrhage partakes of both the active and passive characters just mentioned. The vessels of some particu- lar part may be habitually debilitated, inactive and relaxed, and con- sequently especial^ predisposed to congestion. If in this state, some accidental circumstance supervenes, which increases the general momentum of the circulation, or paiticularly favours the determina- tion of blood to the debilitated vessels, a haeir.orrhage may occur, attended both with general vascular activity, and local torpor and relaxation. This occurs sometimes in hsemorrhois. The effects of sanguineous discharges on the system, are of course various, according to the suddenness and quantity of the evacuation, their duration, and the constitutional habit of the patient. The immediate effects of a considerable loss of blood on the heart and arteries, need not be particularly enumerated. When the has- * Jahn. Klinik der Chron. Krankheiten, Bd. iii. p. 272. HEMORRHAGES. 549 mprrhage is excessive, the respiration becomes quick and difficult, the skin pale and cool; tremors of the extremities, chills, ringing in the ears, dimness of sight, and finally syncope, ensue. When faint- ing occurs, the bleeding usually ceases. In violent cases, the syn- cope may terminate in immediate death; but such a termination is by no means common in spontaneous haemorrhages. More or less reaction usually soon returns, and the bleeding either remains per- manently arrested, or reappears with diminished activity, con- tinuing, in some instances, with occasional intermissions, until the whole system becomes greatly relaxed and exhausted. The secondary effects of prof use or long-continued discharges of blood are often very alarming, obstinate, and even fatal. These remote consequences of haemorrhage are indeed among the most important circumstances connected with sanguineous discharges, whether they be considered in a pathological or practical point of view, and deserve the greatest attention. After the immediate pxhaustion of a profuse or protracted haemor- rhage has in some degree gone off, the whole system is sometimes left in an extremely excitable state. The pulse becomes very fre- quent, throbbing, sharp, moderately full, and compressible; the least corporeal exertion or mental excitement produces agitation, strong beating of the carotids, palpitation of the heart, hurried respiration, and throbbing along the course of the abdominal aorta. In some instances of this kind, the arterial reaction becomes still more vehe- ment. A pulsating, deep-seated pain in the head, and a high degree of morbid sensibility of the brain occur—manifested by great into- lerance of light and sound, and occasionally more or less delirium, with other manifestations of cerebral irritation. This state of tumult- uous reaction and general irritability sometimes gradually subsides, and health slowly returns. In individuals, however, of weak powers of constitutional resistance, this secondary excitement is apt to ter- minate in a state of great feebleness and exhaustion. The patient becomes sluggish both in mind and body; he is disposed to dose, and is inattentive to surrounding objects; the face acquires a pecu- liarly pale and slightly tumid appearance; the pulse is frequent, irregular, and though often large, feels as if the artery were filled with wind. The muscular powers are greatly prostrated; respira- tion is difficult, interrupted by deep sighs, and attended with a pecu- liar crepitus, changing finally to a siight, rattling sound in the trachea and bronchia. In cases of this kind death sometimes supervenes, apparently from infusion into the lungs; in other cases cerebral op- pression, coma, and insensibility, precede for several hours the fatal termination.* In many instances, however, the morbid consequences of haemor- rhages are of a much more chronic character. When the blood- vessels are much drained by copious or protracted sanguineous dis- • Dr. Marshall Hall. Medical Essays, p. 41, 550 HEMORRHAGES. charges, absorption always goes on very actively.* They soon become replenished, therefore, with a crude and watery fluid; the blood is greatly attenuated—containing often but a few ounces of cruor in a pound of the fluid. In consequence of this state of the blood, the heart and arteries are irritated; all the animal and organic functions become enfeebled and sluggish; the face and inferior ex- tremities become more or less oedematous; and the whole surface acquires a peculiarly pale, exsanguious, leucophlegmatic appearance; the mind is torpid; the countenance anxious, or vacant and apathetic; the heart palpitates strongly on the slightest exertion; the hands and feet are cold \ the thirst usually very considerable; and the appe- tite variable, and attended with gastric pain or uneasiness, flatulency, sour eructations, and other dyspeptic symptoms. If the urinary secretion is small, general anasarca, or other forms of dropsy ensue; or colliquative haemorrhage may return, and finally extinguish life. Causes.—The degree of constitutional predisposition to haemor- rhagic discharges varies much in different individuals. Some per- sons appear to be particularly indisposed to spontaneous haemorrhage; whilst others, on the contrary, are naturally very prone to discharges of this kind, although in other respects of vigorous and healthy con- stitutions. In some individuals, there exists so great a constitutional haemorrhagic predisposition, that the slightest wound of the skin is apt to cause the most alarming discharges of blood, and which no applications are, in some instances, able to arrest It appears, more- over, that this extraordinary tendency to haemorrhage is sometimes hereditary. Fordyce relates the case of a man who bled almost daily from the nose. All his children were extremely subject to epistaxis, and one of them died of this affection. Several very re- markable instances of this kind are reported in the second number of the American Medical Review. It appears also that the predisposition to the different varieties of haemorrhage varies with the age of the individual. During child- hood, haemorrhages are most apt to occur from the nose; between puberty and the thirtieth year of age, haemoptysis would seem to be most common; in middle life, haemorrhage from the rectum occurs most frequently; and in very old people, hoematuria is not uncom- mon.! * The experiments of Magendie and others have fully demonstrated this fact. Under the head of dropsy, I have entered more fully into the pathological cir- cumstances which result from this principle. | Cullen's First Lines, vol. ii. The explanation of these circumstances, as given by Cullen, though ingenious and plausible, is far from being satisfactory. It rests too much on the mere mechanical or hydraulic character of the blood- vessels. The intimate relation subsisting between the nervous and vascular sys- tems, as vital structures, and the various sympathetic relations between the dif- ferent organs themselves, subject to variations according to age, are probably much more concerned in the development of these and other predispositions, varying by age, than the circumstances mentioned by Cullen. HEMORRHAGES. 551 With regard to the occasional or exciting causes of haemorrhages, it may be observed, that whatever is capable of producing strong local determinations to soft and very vascular structures, particularly the mucous membranes, may give rise to effusions of blood. The following are the principal causes of this kind. High atmospheric temperature suddenly succeeding cool and damp weather; sudden diminution of atmospheric pressure—hence tte aptitujj^^haeniop- tysis and epistaxis on ascending high mountains. V^ JF^aS8£! tending to obstruct the free return of the blood to the ■P^SjTf ligatures, tumours pressing upon large venous trunks, Iight^rav*«, visceral indurations, and tightly laced corsets; cold repelling the blood from the surface to the internal vessels. Causes that suddenly and greatly increase the momentum of the general, circulation, as violent exercise, lifting heavy weights, stimulating ingesta, and vio- lent mental excitement Exertions that agitate, or over-exercise particular organs, as loud-singing, long-continued speaking, vehe- ment laughing, blowing wind instruments. Substances irritating particular organs, such as cantharides and turpentine acting on the kidneys, sternutatories, or acrid and stimulating inhalations irritating the respiratory organs. General plethora, and obstructions of habit- ual sanguineous evacuations, particularly amenorrhea Finall7> gastro-intestinal irritation, giving rise to strong determinations to the chest or head. •,•„„; Hemorrhages of the active kind, frequently occur as critical evacuations, more especially in the synochal grades of fever Passive sanguineous discharges are never critical, or more correctly speak- ingf perhaps never appear in connexion with a favourable change of the malady in which they occur. . In some instances, hemorrhagic discharges occur periodically. Medicus has collected a number of examples of this kind in his work on neriodical diseases.* Cases occur also, in which the haemorrhage observes a strictly intermittent course-the bleeding returning daily about the same time, and continuing from a few minutes to several hours t I have met with a case of intermitting epistaxis which con- tinued to recur daily for nearly a week. Recamier has related a case of epistaxis in which the bleeding returned every morning and evening for six days in succession.^ Prolnosis.-The prognosis in haemorrhages depends on the con- stitutional habit of the.patient; the ^^^°^^^ discharge- the nature of the organ from which the bleeding occurs, "rSpende^ce, or connexioS with local or general di^ase; he character of the disease with which it may be aviated the Pj°d of febrile diseases at which it supervenes; and the chara^^ ot the occasional causes. Haemorrhage is not often fatal from the mere * Fr. Cas. Medicus. Ge^hichte Periodischer Krankheiten. Hanover, 1784. X Reil, loc. cit. bd. iii. |* 38. X Rev. Medicale, Feb. 1827. 552 HEMORRHAGES. loss of blood. In the course of twenty-two years practice, I have met with but two instances of fatal termination from direct and im- mediate effects of spontaneous haemorrhage. Great diversity in rela- tion to the power of sustaining sanguineous discharges occurs in dif- ferent individuals. In some, immediate and alarming prostration is produced by comparatively small discharges of blood. Others will sustain^a^-—-dingly^pious evacuations with but .little immediate inattJj Rfand shreddy recover their usual vigour and health. rH Hk>f blood wllich may be lost without any dangerous or il^oniRpjences, is indeed in some instances surprisingly great. Bertholini relates a, case in which sixteen pounds of blood were ABpharged from the stomach without any serious consequences. In another instate, he says, the quantity of blood lost from the nose, in thexourse * tlifee days, was still greater.* Nicholai also mentions extraordinary instances of this kind, (Pathologie, b. vi. p. 353.) Haemorrhages, depending on chronic visceral disease, are in general more intractable than such as are free from disorder of this kind. When they occur during the stage of excitement of fevers, their effects are usually salutary, and should not be checked unless they become very copious and debilitating. The haemorrhages which take place in the period of collapse, always portend the utmost de- gree of danger; they seem to depend on a general paralysis of the capillary system, indicative of incipient dissolution. Haemorrhages which depend merely on the local congestion or irritation in an organ, without any constitutional disease, are seldom copious, and usually terminate spontaneously as soon as the local plethora is removed. It is different with those sanguineous discharges, where the local congestion and determination are sustained by some inter- nal or constitutional irritation. In such cases the haemorrhage is particularly apt to continue long, to recur frequently, and to resist the permanent success of remediate applications. The prognosis depends also in some degree on the importance of the organ from which the haemorrhage proceeds. A haemorrhage from the lungs is, cseteris paribus, more to be dreaded than one from the stomach; and this latter is more dangerous than a bleeding from the nose. With regard to the remote consequences of copious losses of blood, it may be obsAwed, that individuals of a relaxed, nervous, phleg- matic, and irritable habit of body, are much more apt to suffer dan- gerous secondary disorders from such discharges, than persons of a contrary physical temperament. Treatment.—The general indications to be kept in view in the treatment of haemorrhages, are: 1. To lessen the momentum of the circulation, if it be above, or at its natural standard; 2. To diminish the determination of blood to, and moderate the local vaseular action in, the part from which the haemorrhage ocoirii; and 3. To excite a contraction of the vessels of the part. Thmnst indication is to be * Anatom. Quintum Renov. 375. Reil, loe. cit. p. 27. EPISTAXIS. 553 fulfilled by venesection and the exhibition of sedatives—as nitre, digitalis, cold, &c. The second indication demands counter-irritat- ing and revulsive applications—such as cold, applied, if practicable, to the part from which the blood flows; and blisters, sinapisms, warmth, and rubefacient frictions, on remote situations. The last indication requires the internal use of astringents—such as sugar of lead, alum, muriated tincture of iron, &c; and where the situation of the part will admit of it, the external application of styptics. Having made these general observations on haemorrhages, I pro- ceed to the consideration of the particular varieties, according to the part from which they proceed. 1. Epistaxis.—Bleeding from the nose. This is by far the most common variety of haemorrhage. As has already been observed, epistaxis occurs most frequently in early life, particularly about the age of puberty. The eruption of the blood is often preceded by symptoms indicative of a congested state of the vessels of the head—as a sense of weight and tension in the temples; violent beating pain in the head; throbbing of the carotids; flushed face; giddiness; ringing in the ears; and a sense of tickling, tension, or stinging pain in the nose. In weak and irritable persons, other symptoms, in addition to these, denoting a nervous and spasmodic condition of the system, are apt to occur—namely, slight creeping chills; disposition to syncope; cold extremities; a constricted state of the skin; and a small, corded, and quick pulse. In general, only a few ounces of blood are discharged, and with this small loss of blood all the foregoing symptoms disappear. Sometimes, however, the blood flows so copiously and continuedly as to become alarming, and to demand active measures for its suppression.* The blood very rarely proceeds from both nostrils. Causes.—The exciting causes of epistaxis are exceedingly vari- ous. Whatever has a tendency to produce a preternatural determi- nation of blood to the head, may give rise to this variety of haemor- rhage; such as insolation, stimulating ingesta, protracted study, the warm bath, sneezing, coughing, playing on wind instruments, vio- lent parturient efforts, straining in evacuating the bowels, a depend- ing position of the head, violent affections of the mind, strong blushing, intestinal irritation,hea\y lifting,&c. Chronic visceral disorders, particularly indurations of the spleen and liver, strongly predispose to epistaxis, and this haemorrhage appears sometimes to be the consequence of organic affections of the heart and of the .large vascular trunks. Suppression of the menstrual and haemorrhoidal evacuations, may give rise to this haemorrhage; and it never fails to * Plouquet has collected a number of instances in which unusually large quan- tities of blood were discharged from the nose without fatal consequences.—Bib- liotheca Medico Pract. vol. Iv. p. 69. Vol. I.—70 • 554 EPISTAXIS. occur in that attenuated and watery state of the blood which usually follows copious, sanguineous, and other evacuations, in relaxed and leucophlegmatic habits. Bleeding from the nose is no uncommon occurrence in dropsical patients, and in the latter stage of cachetic diseases, particularly scurvy. Prognosis.—Epistaxis is seldom of much consequence when it is not symptomatic of some serious visceral or general affection. When, h6wever, it occurs readily and frequently in early life, it would seem to indicate a particular predisposition to haemoptysis and phthisis pulmonalis; and frequent or habitual epistaxis, in mid- dle and advanced age, may be regarded as a pretty sure indication of the existence of organic visceral disease, and of a strong tendency to dropsy or apoplexy, according to the general physical tempera- ment and structure of the individual. Haemorrhages from the nose, in inflammatory fevers, and in the stage of excitement of every form of fever, typhus, as well as malignant, are to be regarded as salutary; but when they occur in the sinking stage, or period of collapse, they manifest a highly dangerous condition. This, as indeed all other varieties, of haemorrhage, is most apt to become troublesome and dangerous in debilitated, relaxed, and irritable subjects; more especially, when the blood, at the same time, is thin and watery, or dissolved, as in scurvy. The most unmanageable haemorrhages from the nose, are those which depend on some abdominal irritation or obstruction, in connexion with an attenuated state of the blood. Epistaxis is, however, very rarely fatal from the immediate effects of mere loss of blood, although, like- other varieties of sanguineous discharges, it may lead to a train of distressing and dangerous chronic affections. Treatment.—In being called to a case of epistaxis for remediate aid, the first and most important question is:—Are the circumstances preceding and accompanying the haemorrhage; and is the haemor- rhage itself of such a character as to render it most proper to arrest it, or to suffer it to go on until it ceases spontaneously? When the haemorrhage occurs in consequence of suppressed menstrual or hae- morrhoidal discharge, it ought not to be interfered with, unless it becomes excessive; and the same observation applies to the occur- rence of this evacuation in the stage of excitement of febrile affec- tions. In general, whenever epistaxis is attended with an active pulse, and symptoms of cephalic congestion, no attempt should be made to arrest the bleeding by local applications; but, on the con- trary, nature should be assisted in the reduction of the vascular excitement by venesection, rest with the head in an elevated posi- tion, cold drinks, laxatives, and nitre. The last article, given in large doses, is often particularly beneficial, in cases of considerable arterial excitement. I have used it in every variety of active haemor- rhage with prompt and complete success, without any auxiliary application. This mode of proceeding is especially necessary in persons of robust and plethoric habits, and in such as are subject to EPISTAXIS. 555 hemorrhoidal discharges. But when nasal haemorrhage occurs in weak, nervous, and cachetic individuals, and particularly when the manifestations of general vascular turgescence and increased mo- mentum of the circulation are absent, the sooner it is arrested the better. In moderate cases, it will often be sufficient to apply cold water to the temples, head, and nape of the neck, while the head is kept in an elevated position. Richter asserts, that cold water applied to the genital organs, has a sudden and powerful effect in arresting bleeding from the nose. If the haemorrhage should not yield to these simple measures, small doses of sugar of lead may be given internally. This is decidedly the best internal astringent in every variety of active haemorrhage.* From one to two grains may be given every half hour until the bleeding is checked; and, in most cases, its effects are promptly successful. The galic acid, also, is said to be a very powerful styptic for the cure of this and other varieties of internal haemorrhage. Dr. A. T. Thomson, has lately published the result of his analysis of Ruspini's celebrated styptic, and from this it would appear, that its active principle is the galic acid—Ruspini's styptic is, according to Dr. Johnson's experience, " unquestionably the most powerful restrainer of haemorrhage which we possess;" and as its price is " enormous," it is much to be hoped that Dr. Thomson's analysis may be correct Be this as it may, experience has shown that the galic acid is a powerful agent for re- straining internal haemorrhages. In general, the haemorrhage may soon be permanently arrested by these means; but where the haemor- rhagic disposition is strong, or in relaxed and debilitated habits, the bleeding, though checked for a time by applications of this kind, is apt to return again and again, until the system becomes greatly ex- hausted. In cases of this kind, we may generally succeed in putting a permanent stop to the discharge, by applying a blister to the back of the neck; and in order to obtain vesication speedily, the skin, where the blister is to be applied, should be previously well rubbed with the terebinthinate decoction of cantharides, oil of monarda punctata, or some other active rubefacient. Warm pediluvium is always a useful auxiliary remedy, by deter- mining the circulation to the inferior parts of the body; or, instead of this, sinapisms may be applied to the ankles or soles of the feet. Local styptics are recommended in obstinate cases, but they are very rarely of much avail, and may even do mischief by the irrita- tion they cause in the sny derian membrane, and the consequent afflux of blood. Nevertheless, in obstinate and alarming cases, a dossil of lint, dipped in some astringent solution, should be introduced into the nostril, and passed up to the part from which the blood issues. * Various other internal astringents have been recommended—as, the sul- phate of zinc, alum, sulphate of copper, gum kino, and the muriated tincture of iron. They are, however, greatly inferior to the sugar of lead. 556 HEMATEMESIS. In general, however, simple compression, by plugging up the nostril with lint, will answer all the purposes that can be obtained from applications of this kind. The patient must be cautioned against blowing his nose, as well as against every thing which may excite the arterial system. Upon the whole, bleeding, purgatives, and nitre, with cold water to the head, warm pediluvium, or sinapisms to the feet, blisters to the back of the neck, the internal use of sugar of lead, and finally, mechanical compression, are the remedies which must be relied on in this variety of haemorrhage. 2. Hsematemesis.—Haemorrhage from the stomach. The promonitory symptoms of haemorrhage from the stomach, are, in general, conspicuous. They consist in a sense of weight and pressure in the epigastrium; loss of appetite, or voraciousness; foul breath; acid eructations; pain and tenderness in the hypochondria; nausea; anxiety; ringing in the ears; disposition to syncope; a small, contracted, and irritated pulse; alternate flushes of heat and chills; palpitation; cold extremities; a pale and contracted countenance; and finally, extreme anxiety; and weakness and constriction about the breast; the senses become confused; great sickness of the stomach, with a feeling of approaching syncope; and at last, copious ejections of blood from the stomach, ensue. The blood thrown up is gene- rally of a very dark colour, sometimes in coagulated clots, and at others quite fluid. Occasionally, however, it is florid and liquid. Instances are mentioned, in which small masses of concreted lymph, deprived of the cruor, resembling pseudo-membranous structures, were thrown up.* Sometimes, the blood ejected is of a black colour, resembling tar. In cases of this kind, the haemorrhage probably proceeds from the liver. In malignant fevers, particularly in yellow fever, the discharge resembles coffee-grounds suspended in a glairy fluid. This would seem to be generally the case when the haemor- rhage arises from inflammation and abrasion of the mucous mem- brane of the stomach. In some instances, partial syncope follows the vomiting, and the patient complains of pain in the region of the spleen and in the lower part of the abdomen. The quantity of blood thrown up at once is often very great. Instances of fatal haemor- rhage in the stomach have occurred also, in which little or no blood was discharged, (Richter;) and in some cases the blood passes off by the bowels with little or no discharge by vomiting. After the blood which had gradually accumulated in the stomach is*thrown off, the patient generally soon feels greatly relieved, though often much exhausted. Very frequently, however, the same train of symptoms already mentioned return, after a longer or shorter interval, and ter- minate in another spell of vomiting of blood; and the haematemesis may thus recur several times before it finally ceases. * Reil. Fieberlehre. B. iii. p. 134. HEMATEMESIS. 557 The haemorrhage no doubt generally occurs from the mucous membrane of the stomach, but it is thought also to proceed in some cases from the liver or spleen. When the blood comes from the former organ, it passes along the common bile duct into the duode- num, and thence regurgitates into the stomach. When the spleen is the source of the haemorrhage, if this be ever the case, the blood, it is supposed, gains admission into the stomach through the vassa brevia. Richter observes that the frequent tumefaction of the spleen, a short time before the occurrence of haematemesis, as well as the morbid or unnatural condition of this organ in those who die of this disease, render this opinion very probable. It is more likely, however, that the spleen is no further concerned in the production of this haemor- rhage than by the congestion which it is peculiarly calculated to produce in the vessels of the stomach when its own structure becomes engorged or indurated. The darker and more coagulated the blood is when thrown up, the slower we may presume must have been the haemorrhage, or the longer it must have lain in the stomach. A portion of the effused blood always gains admission into the bowels, and hence generally dark, grumous, alvine discharges, occur for several days after an attack of haematemesis. Causes.—Every thing which tends to impede the free circulation of the blood in the abdominal viscera, may give rise to this variety of haemorrhage. Among the circumstances which tend most parti- cularly to this effect, are indurations of the liver and spleen. It occurs also in consequence of suppressed haemorrhoidal discharge, more especially when favoured by an indulgence in the pleasures of the table, or by an inactive and sedentary mode of life. In no sub- jects, however, is vomiting of blood more apt to occur than in young * females, soon after the age of puberty, labouring under menstrual irregularities. It appears also occasionally to arise from pregnancy, and from the final cessation of the menses at the critical period of life. Various local causes may produce haematemesis, such a3 acrid or corroding substances received into the stomach; blows on the epigastrium; and it takes place sometimes in the last stage of malig- nant fevers. The blood may proceed from the nose, and gradually descend into the stomach. This occurs sometimes in patients con- fined to bed by other diseases. In such cases, however, the quantity of blood thrown up is always small, and the vomiting is not preceded by the spasmodic and painful affections of the stomach mentioned above. Prognosis.—When haematemesis occurs in consequence of sup- pressed haemorrhoidal or catamenial discharge, it is not in general attended with much immediate danger, unless the vomiting returns frequently, in which case it seldom fails to lead to a train of distress- ing and dangerous consequences, such as dropsy, inveterate dyspep- sia, hysteria, hypochondriasis, and great languor, relaxation, and debility. It is most dangerous when it arises from visceral obstruc- 558 HEMATEMESIS. tions, particularly in persons who ar£ addicted to the intemperate use of spirituous liquors. There is no variety of haemorrhage more apt to become habitual than this one. Tissot relates a case which recurred regularly every month, instead of the menstrual evacuation, without any evil consequences whatever. Treatment.—The momentum of the circulation must be dimin- ished by venesection when it is above the natural standard. A large sinapism should be immediately applied to the epigastric and hypochondriac regions, in order to derive the blood as much as pos- sible from the vessels of the stomach. Dry cupping may also be beneficially used for this purpose; and warm pediluvium will assist materially in deriving the circulation from the congested abdominal viscera. Laxative enemata should be administered. In that variety of haematemesis which attacks females between puberty and the age of thirty, purgatives, according to the experience of Dr. Hamilton, are among our most valuable remediate means. There is generally in cases of this kind considerable menstrual irregularity, caused ap- parently by a loaded and torpid state of the intestinal canal. Free purgation, by exciting the portal circulation, and removing the in- testinal irritation, will generally prevent the recurrence of the hae- morrhage in cases of this kind. I have in a few cases known decided benefit obtained from the use of active and repeated purgatives in this affection. Dr. Sheridan has published some cases which go to show that emetics will sometimes do much good in this variety of haemor- rhage. He states that his father had used this remedy with great advantage in haematemesis, more than fifty years ago. I have not myself employed emetics in this affection; but I understand that Dr. Chapman has resorted to them with much benefit. Ipecacuanha would appear to be the proper emetic. Various astringents have been recommended in this affection. Saccharum saturni; galic acid; muriated tincture of iron; spirits of turpentine; alum-whey; muriate of soda; kino; cold water; and a variety of astringent vegetable infu- sions, have been employed and praised for their effects. The sugar of lead does not appear to be as efficient in this as in the other varie- ties of haemorrhage, although without doubt the best astringent we possess in this affection. Indeed, internal astringents can afford but little advantage when the disease depends on obstructions of the liver or spleen, or upon some other chronic impediment to the regular circulation of blood in the portal circle. I have nevertheless derived very great advantage from the use of the spirits of turpentine with castor oil, in purgative doses, in several cases of haematemesis. In cachectic and debilitated subjects, more especially in chlorotic fe- males, the muriated tincture of iron sometimes affords peculiar ad- vantages. Burserius recommends the use of copious draughts of eold water in this affection. The expressed juice of the common nettle, (urtica dioica,) has been much extolled for its effects in this haemorrhage, and I have known it used with apparent benefit HEMATURIA. 559 The diet should be of the lightest and most unirritating kind, and the drink bland, cool, and acidulated. After an attack of this dis- ease, the diluted sulphuric acid will generally be useful in restoring the tone of the stomach, and checking the tendency to sanguineous effusion. 3. Hematuria.—Hsemorrhage from the urinary organs. It is often difficult to say whether the haemorrhage in bloody urine comes from the bladder, the ureters, or the kidneys. As it is of some importance in a practical point of view, to form a correct opinion concerning the source of the bleeding, it will be proper to point out the diagnostic circumstances particularly. When the blood passes off unmixed with urine, or without an effort to evacuate this secretion, the haemorrhage, it may be inferred, proceeds from some part of the urethra, (stimatosis.) When the discharge of bloody urine is attended with a stinging or dull pain about the neck of the bladder, and a sense of fulness and uneasiness in the perinaeum, accompanied with frequent painful erections, and burning pain in the glans penis and anus, and the blood comes off in small flocculi, intermixed with pretty large coagula floating in the urine, there is good reason to infer that the haemorrhage proceeds from the bladder. The coagula sometimes block up the neck of the bladder or urethra so completely as to cause complete suppression of the urine, and render the introduction of the catheter necessary to procure its evacuation. In haemorrhage from the kidneys or ureters, the blood is always very intimately mixed with the urine, so as to give to the discharge a uniform bloody appearance, without flakes, or small coagulae. After the urine has stood some time, the blood subsides to the bot- tom of the vessel, into a uniform paste-like substance, leaving the supernatent urine clear. In haemorrhage from the kidneys, the patient in general experiences little or no unpleasant sensations in the bladder; but in the region of the kidneys more or less pain and uneasiness is always felt, and there is usually a retraction of the tes- ticle on one side, with a feeling of numbness of the thigh. Haematuria sometimes occurs periodically. This is most apt to be the case when the haemorrhage proceeds from the neck of the bladder, and is attended with an irregular or ineffectual haemor- rhoidal effort in the system. I am now attending a gentleman who has been regularly affected with bleeding from the bladder every two months for the last four years. He was formerly much troubled with hsemorrhois, but since the present complaint began, he has had no haemorrhage from the rectum. , This variety of hsemorrhage is most apt to occur in old people- more especially in such as have been much affected with haemorrhois, or in such as are of a gouty habit. Richter says that plethoric and corpulent women are peculiarly liable to hematuria about the period 560 HEMATURIA. of the final cessation of the catamenia. It is not uncommon to meet with this affection in very young children during dentition. Causes.—Haematuria is often excited by calculous concretions in the kidneys and bladder, and by acrid or stimulating diuretics, as cantharides, spirit of turpentine, garlic, and other similar substances. It arises also from organic affections of the urinary organs. Scir- rhus, ulcerations, and vascular or fleshy tumours in the bladder, ureters, and kidneys, may produce it. In some instances, the hae- morrhage occurs from a varicose state of the mucous membrane of the bladder; and it would seem that a highly congested condition of this membrane from chronic inflammation, is sometimes the cause of this affection. When the predisposition to the disease is strong, it may be readily excited by whatever is capable of increasing the general momentum of the circulation, and particularly by mechani- cal agitation of the urinary organs. There is a gentleman in this city who has been affected with bloody discharges from the bladder, at short intervals, for more than six years. It is frequently brought on immediately by active exercise, and especially by riding in a car- riage over a rough pavement. It is not connected with calculus, nor with pain, though often accompanied with a sense of weight, pressure, and uneasiness, about the neck of the bladder. One of the most frequent causes of haematuria in advanced age is an ineffectual haemorrhoidal effort, or suppression of this discharge after it has become habitual. Haemorrhage from the urethra frequently occurs in gonorrhoea, in consequence of irritating injections. This variety of haemorrhage is seldom attended with alarming effects from the mere loss of blood. When it occurs in the latter stage of violent grades of fever, it is indeed one of the most fatal signs. Frequent and copious haemorrhagic discharges from the blad- der in old people is particularly apt to lead to dropsical effusions. (Richter.) When, however, it occurs vicariously in the place of haemorrhois or menstruation, it is rarely followed by serious conse- quences; nor is this haemorrhage attended with danger when it arises from irritating diuretics, from dentition, or from overheating, unless it be connected with considerable inflammation. Persons who have once been affected with this complaint, are in general particularly liable to a return of it from the action of any of its exciting causes. Treatment.—In plethoric and young subjects, an attack of haema- turia, like any other haemorrhage in such a habit, requires a prompt reduction of the momentum of the circulation by venesection. When the haemorrhage depends on calculous irritation in the kid- neys, the warm bath, assisted by opium and sugar of lead, are gene- rally decidedly beneficial. A quarter of a grain of opium with a grain of sugar of lead, may be given every hour, until the pain and irritation are allayed. Free venesection should, however, be pre- mised in such cases; and much advantage may also be obtained from HEMATURIA. 561 cupping and sinapisms over the region of the affected kidney. Along with these measures, copious draughts of mucilaginous diluents should be taken, more especially when the renal irritation arises irom acrid diuretics, or other substances taken internally. The uva ursi has been much recommended for the cure of this affection; but although 1 have tried it repeatedly, I have never yet derived any obvious benefit from it. Dr. A. T. Thomson says, that "the addi- tion of some galic acid to a tincture of uva ursi, will be found to answer every indication that can be expected from the emp oyment of astringents in hematuria.* When the haemorrhage is not attend- ed with symptoms of renal irritation, or pain in the region of the bladder, the muriated tincture of iron, with the free use of mucilagi- nous drinks, will often do much good. I have in several instances found this astringent decidedly beneficial, after the sugar of lead had failed to procure any advantages. From twelve to twenty drops ot this tincture may be given, three, four, or five times daily, according to the urgencywof the symptoms. In all instances the diet should be light, unirritating, and digestible, and all kinds of stimulating beverages, and active diuretics, most carefully avoided.! In one case of long standing, I succeeded in putting a permanent termina- tion to the hemorrhage by small doses of alum and ipecacuanha,* in conjunction with a milk diet, mucilaginous drinks, and the occa- sional use of a mild aperient. Reil recommends cold and bland in- jections into the bladder when the blood proceeds from this viscus. He mentions also strong coffee, with laudanum, taken occasionally, as useful when this affection is attended with difficulty and pain in voiding the urine. In habitual haematuria, a caustic issue on the upper and inner part of theMhigh, or near the grom on the abdomen is said to have proved very.beneficial. (Richter.) In recen cases of an obstinate character, we may sometimes make a successful impres- sion on the disease by sinapisms applied over the sacrum 1 have known this application to arrest a copious hemorrhage from the bladder after various other'measures had been adopted withou avail Various astringent vegetable infusions have been employed and recommended in this variety of haemorrhage, but they seem to be of little value. In chronic and moderate cases, we may employ ^dSLcSnTlogwoodwith occasional benefit. Where the blood moceeds from thegurethra, cpld water or ice should be kept applied to the genitals. This will seldom fail to put a stop to the bleeding We mfy also inject cold solutions of the sugar of lead in cases of * Ed. Med. & Phys. Jour. Jan. 1831. + Burserius relates an instance of obstinate hematuria, which was cured by a long course of milk diet, without any other remedies.-/™**™™. Med. Pract. vol. iv. p. 487. + R__Pulv. aluminis 3'u + _____ipecac. gr. xx.—M. Divide into tun equal parU;. b. Take one every morning, noon, and evening. Vol. 1—71 562 HEMOPTYSIS. this kind. The patient should not be permitted to use any exercise in recent cases. Perfect rest is often essential, particularly when the haemorrhage is attended with manifest local and general irrita- tion. 4. Haemoptysis.—Hsemorrhage from the lungs. This term is applied to haemorrhages from the respiratory pass- ages, whether they proceed from the larynx, the trachea, or the bronchia. In its concomitant phenomena, degrees of violence, and duration, haemoptysis varies very much. In many instances the quantity of blood brought up is very small; in some cases it is dis- charged in considerable, but not exhausting quantities; and occa- sionally the bleeding is sudden and exceedingly copious. Active haemorrhage from the lungs is often preceded by certain premonitory symptoms; such as a feeling of heaviness and lassitude in the extremities; anxiety; stricture across the breast; short cough; palpitation of the heart; deep and frequent sighing; a deep-seated, pungent, or burning pain under the sternum, and slight creeping chills; cold hands and feet; alternate paleness and flushing of the face; mental and corporeal irritability; a quick, small, frequent, and corded pulse; and often a disagreeable salty or sweetish taste in the mouth. After these symptoms have continued for a longer or shorter period, the patient usually begins to feel a sense of warmth in the breast, gradually rising up towards the larynx, attended with a saltish taste. Slight coughing now ensues, or an effort is made to hawk, and the blood makes its appearance. In many cases, how- ever, the haemorrhage comes on suddenly, without any premonitory symptoms whatever. When this is the case, there is commonly but little blood discharged at a time; but the hemorrhage is apt to re- turn frequently for several weeks, and even months. The blood is usually very florid and* frothy, particularly when it proceeds from the trachea and larger bronchia. In malignant fevers, scurvy, gangrene, of the lungs, and in the pneumonia of old people, the blood, however, is dark, and sometimes almost black, and gene- rally dissolved. When the hemorrhage proceeds from the fauces, the blood is generally spit out without coughing; and when it comes from the cavity of the mouth, there is usually neither coughing nor hawking in throwing out the blood. In some instances, however., when the bleeding is profuse, the blood descends and irritates the glottis, giving rise to a mixed effort of coughing and vomiting, which may readily lead to the supposition that the blood proceeds from the lungs. Portal mentions a singular instance, which was treated unsuccess- fully for hemorrhage from the lungs. The quantity of blood cough- ed up was very copious, and although frequently checked, recurred again and again until the patient sunk under it. On dissection, the t HEMOPTYSIS. 563 bronchial glands were found mueh tumefied—some of them as large as a hazel-nut, and charged with a large quantity of black fluid. The lungs were sound, but the bronchial cells were filled with a dark grumous fluid. In most instances, those who have once suffered an attack of spit- ting of blood, are subject to returns of it at irregular periods; and in some rare instances this affection has been known to return periodi- cally. Schroeder mentions a case in which a considerable portion of blood was coughed up every morning for many days in succes- sion, not the least hemorrhage having occurred during the rest of the day; and Alexander Thompson relates an instance, in which hemorrhage from the lungs came on every third day with perfect regularity for upwards of a year. Reil also saw a case of quotidian hemoptysis in a female, which continued for two years. The bleed- ing always occurred in the morning. Cases in which hemorrhage from the lungs returned monthly, are mentioned by Amatus Lusi- tanus, Schenk, Meyer, and Mead; and Richter mentions an instance in which it occurred every four weeks instead of the menstrual evacuation, for upwards of twenty-five years. (Spec. Therap.) Blanchard saw an instance of its recurrence for a long period (every three months) in consequence of suppressed hemorrhoidal dis- charge.* Predisposition.—The period of life most favourable to the occur- rence of this variety of hemorrhage, is between the fifteenth and thirtieth years of age. Some individuals are constitutionally pre- disposed to it; and, indeed, in the majority of cases, in which it occurs spontaneously, such a predisposition lies at the bottom of the disease. This predisposition would seem to consist in an irritable state of the circulatory system generally; and in a delicate organiza- tion of the pulmonary system. The habit of body—so far as its physical conformation may be concerned—which seems most gene- rally connected with a particular predisposition to this hemorrhage, consists in a narrow, flattened, and depressed chest; high, promi- nent, square shoulders; a long and slender neck; a general slender, and delicate frame of body; fair hair, and blue eyes; a delicate and fair skin, through which the superficial veins are conspicuous; red cheeks; sound white teeth; and a clear, but not powerful voice. Such individuals are of a sanguineous temperament; irritable, pas- sionate, full of activity, but incapable of enduring much exertion; they are apt to be troubled with irregular determinations of blood, particularly to the head; and slight exciting causes create palpitation of the heart and general arterial excitement. During early youth, persons of this temperament and habit, are apt to be affected with glandular swellings about the neck; eruptions on the scalp and be- hind the ears; and as they advance in age, with slight catarrhal affections, which frequently go off slowly with a copious expectora- * Medicus. Geschichte Periodischer Krankheeten. Th. i. p. 115. > 564 HEMOPTYSIS. tion. In such individuals, after they have passed the age of puberty, the ordinary exciting causes of hemorrhages are particularly apt to give rise to spitting of blood. Causes.—The exciting causes of hemoptysis are, of course, ex- tremely various. The following are among the most common and powerful. Atmospheric vicissitudes; violent bodily exertions; the intemperate use of stimulating drinks; the suppression of habitual evacuations; the sudden drying up of old ulcers; repercussion of cutaneous eruptions; suppressed habitual sweating of the feet; metas- tasis of gout; rheumatism; irritating substances acting directly on the mucous membrane of the lungs, as the inhalation of fine irritat- ing particles floating in the air, or of gaseous substances; intestinal irritation; organic diseases of the heart; obstruction of the spleen or liver; a sudden diminution of atmospheric pressure; breathing a very heated air; blows on the chest; costiveness; loud speaking, or sing- ing; violent mental excitement; and organic affections of the lungs, impeding the free circulation of the blood through its vessels, parti- cularly tubercles. Hemoptysis sometimes follows the amputation of a limb, or the taking up of a large artery. Prognosis.—Hemoptysis seldom proves fatal from the mere loss of blood. It is, nevertheless, generally of very serious import— being, in many instances, the forerunner or attendant of phthisis pulmonalis. It is not, however, always followed by consumption, or even connected with a phthisical habit Instances of pulmonary hemorrhage not unfrequently occur without any dangerous conse- quences whatever; and this is more apt to be the case when the dis- charge comes on suddenly and profusely, than when there is an ex- pectoration merely streaked with blood; The prognosis as to the remote consequences, depends, however, much on the presence or absence of the general manifestations of. a scrofulous or phthisical habit mentioned above. Where these indications are unequivocal, the occurrence of hemorrhage from £he respiratory passages, is always to be regarded as highly dangerous. When this hemorrhage occurs from pregnancy or suppressed catamenial or hemorrhoidal discharge, there is usually no reason to apprehend any very serious consequences, if a predisposition to consumption does-not.exist. In general, hemoptysis, resulting from causes which suddenly produce strong pulmonary congestion, or general arterial excitement—such as lifting heavy weights, or other violent bodily exertions; loud singing or declaiming; playing on wind instruments; over-distention of the stomach; stimulating drinks, &c. is much less apt to lead to dangerous consequences than cases that occur spontaneously. Treatment.—The remediate management of hemoptysis divides itself into that which is proper during the actual existence of the hemorrhage, and that which should be pursued after the bleeding is arrested. When the pulse is frequent, tense, or hard, the momentum of the circulation should be immediately reduced by venesection) and to t HEMOPTYSIS. 565 effect this purpose adequately, it is often necessary to abstract blood very copiously. In some instances, the pulse will be found very small, but tense and firm to the touch; and in such cases it is parti- cularly important to resort to prompt and very free venesection. At the same time that this step is taken, large portions of common salt,* or small doses of sugar of lead, should be administered at short intervals, until the hemorrhage is checked. A large sinapism should also be applied over the breast, as soon as the activity of the pulse is reduced. Perfect rest and cooling drinks should be rigidly enjoined. If the feet are cold, warm applications or sinapisms ought to be applied to them; and the patient may take an occasional draught of cold water.X If the bowels are constipated, the rectum should be emptied by laxative enemata. In cases of this kind, large doses of the nitrate of potash will often promptly arrest the hemorrhage; and in a manifestly phlogistic state of the system, it is decidedly the best internal remedy we possess in this affection. This article was long ago strongly recommended by Selle;J and Richter speaks very favourably of its powers in this disease. Dickson also gave it in very large portions, dissolved in mucilaginous fluid, in this affection, with much benefit ;§ and we may likewise cite the experience of Gibbon,|| and Hartmann,1T in favour of its excellent effects. In Italy it has of late years been greatly extolled as a remedy in hemoptysis, and, according to my own experience, not more than it deserves. Recamier has within a few years reported some cases illustrative of its beneficial effects in this variety of hemorrhage. He gave half an ounce of nitre, dissolved in a mucilaginous mixture, in the course of twenty-four hours, and in this way three cases were promptly relieved after bleeding and other remedies had been used ineffectu- ally.** From fifteen to twenty grains of this article, dissolved in a small cup of barley-water or some other mucilaginous fluid, may be * This article was first introduced to the notice of the profession, as a prompt and efficient remedy in hemoptysis, by Dr. Rush. It would seem, however, from Schopfs account of his Travels in the United States, (Bd. i. p. 116,) that the knowledge of its powers in this way was first brought to this country from Ireland, by Schiel. F. Hoffman and Fordyce assert, that a solution of sulphate of soda will often do more good in haemoptysis than any other remedy. • f Burserius (Inst. Med. Pract., vol. iv. p. 33,) says much in favour of the use of frequent draughts of cold water, (the temperature of which is to be lessen- ed from time to time, until it is at last taken as cold as ice,) in this variety of haemorrhage. X Medicina Clinica. Berlin, 1797. p. 147. § Lond. Med. Obser. vol. vi. No. XVI. || Medical'Cases and Remarks. Lond. 1800. If Nova Act. R. Soc. Scient. Upsal. vol. i. p. 109, as quoted in Richler's Aus- fuhrliche Arzneimittellehre, vol. iv. p. 242. ** Med. Chir. Rev. January, 1826. 566 HEMOPTYSIS. taken every half hour or hour, until the bleeding is checked. A great variety of internal astringent remedies have been recommended in this affection—such as alum, colcothar of vitriol, sulphate of cop- per, sulphuric acid, &c.; but they are all much inferior, in efficacy, to the sugar of lead. This article may be given in doses of from one to five grains every half hour, or at longer intervals, according to the rapidity of the hemorrhage. It appears to be equally appli- cable in cases attended with an active or debilitated state of the cir- culation. I have generally given it in union with calomel, where the diathesis was phlogistic; but in cases attended with a nervous or spasmodic condition, opium is the best adjuvant. In cases attended with an irritated, small, frequent pulse, with a pale and contracted countenance, cold extremities and a dry skin, small doses of sugar of lead, in combination with opium and calomel,* will generally procure prompt relief. Richter and Mezat recom- mend ipecacuanha in such cases. The former writer states that he has often promptly arrested hemoptysis, attended with cold extremi- ties, alternate flushing and paleness of the face, limpid urine, small and hard pulse, and much anxiety in the chest, by exhibiting a quar- ter of a grain of ipecacuanha every fifteen minutes. (Specielle Therapie?) It is in instances of this kind, that emetics may be given with advantage. Whenever a congestive state of the pulmo- nary system is present in this affection, with deficient action of the cutaneous capillaries, vomits will be likely to prove serviceable. They were formerly much, and too indiscriminately, recommended, by some practitioners. (Brian Robinson.) In ordinary cases, at- tended with a plethoric and excited state of the system, they are unquestionably hazardous. In the spasmodic and nervous cases just mentioned, Harles,J Stork, Richter, Plater, and others, speak very favourably of hyoscyamus. Harles particularly recommends an oil prepared by boiling the leaves of this plant in flaxseed oil; and F. Hoffman considers the extract, given in doses of from one to three grains every hour, as one of our best remedies in such cases. According to Dr. Miner's experience, the powdered capsicum, given in doses of from three to five grains every ten minutes, is a most efficient remedy in hemoptysis. I have had occasion to pre- scribe this article in one instance lately, and the result has given me a very favourable impression of its powers in this respect. When spitting of blood assumes a chronic character, and is attend- ed with an irritated state of the pulse, digitalis sometimes does much * R.—Calomel gr. vi. Pulv. acetat. plumbi. gr. xii. ----opii gr. iii.—M. Divide into 12 equal parts. Give one every thirty minutes if the haemorrhage is considerable, or every two heurs in less rapid cases. X Reil. Fieberlehre. Bd. iii. p. 107. X Hufeland's Journal der Pract. Heilkund. B. ix. s. ii. p. 47. HEMOPTYSIS. 567 good. From one-fourth to half a grain of the powdered leaves, or from fifteen to twenty drops of the tincture, may be taken every four hours, until a manifest impression is made on the pulse. It will be proper to keep the system moderately under its influence for ten or twelve days. In cases of this kind, much advantage will, in general, result from blistering the breast—or, what is still better, pustulating this part with tartar emetic ointment, or establishing a more permanent discharge by a caustic issue or seton. The nature of the occasional cause should be particularly kept in view in regulating the treatment of hemorrhage, and especially for the prevention of its recurrence. When hemoptysis supervenes in consequence of suppressed he- morrhoidal discharge, advantage may be obtained from the use of small doses of aloes, and particularly from the application of leeches to the anus. These measures are particularly useful in conjunction with a light diet, moderate exercise, and an occasional general bleed- ing, to obviate the return of the hemorrhage from the lungs. When the disease appears to arise from general plethora, in conse- quence of a free indulgence in the pleasures of the table, and an indo- lent course of life, or sedentary habit, it will be necessary to enjoin a simple, unirritating, and moderate diet, cooling drinks, moderate exercise, and the avoidance of all kinds of stimulating beverages. Should the hemoptysis be dependent on irregular, gouty irritation, or rheumatism, especial advantage may be gained from setons or is- sues on the inferior extremities, and a course of treatmeut calculated to counteract these affections. When abdominal indurations exist, or intestinal irritation from a loaded state of the bowels, or acrid secretions, a gentle course of mercurial and aperient remedies, the extract of taraxacum, and other deobstruents, with a regulated diet and exercise, will be most likely to ensure exemption from a subsequent attack of the hemorrhage. If the bleeding appears to be excited by a violent cough, attended with irritation of the respiratory passages, expectorants, demulcents, leeching and cupping on the chest, venesection, and opiates, are particularly indicated. In such cases frequent doses of flaxseed oil are said to be very beneficial.* When the cough is violent and spasmodic, and the pulse contracted and small, with a dry skin, small doses of camphor and ipecacuanha, with mucilaginous drinks, often procure great and speedy relief. (Richter, Specielle Therapie, Bd. iii. p. 297.) Wnen hemoptysis occurs in young females from menstrual ir- regularities, we may resort to the tincture of cantharides, venesection, blisters to the sacrum, riding on horseback, and the warm hip-bath; but the ordinary stimulating emmenagogues must be carefully avoid- ed. When cases of this kind are attended with a chlorotic, or slug- gish and relaxed state of the system, the ferruginous preparations, * Journal de Med. tom. xxx. p. 85. 568 MENORRHAGIA. the tincture of cinnamon, exercise by gestation, a nourishing and digestible diet, with aloetic aperients, &c. may be properly used. I have employed the following pills with obvious benefit in two in- stances of this kind.* 5. Menorrhagia.—Haemorrhage from the uterus. Uterine hemorrhage appears under a great variety of modifica- tions, both in relation to its phenomena and causes. Under the present head, however, I shall treat only of those hemorrhagic dis- charges which occur in the unimpregnated state of the uterus—ex- cluding also such as depend on organic or structural disease of the womb. In some instances, the menstrual secretion becomes so copious as to cause much debility and exhaustion, and to require remediate interference. In many females, the flow of menses is always very large, who nevertheless enjoy a state of vigorous health. In instances of this kind, the discharge must not be regarded as morbid, or im- moderate, however copious it may be; for if the system sustains no inconvenience from it, it is to be viewed as natural, or consistent with the constitutional habit of the individual in whom it occurs. So long, therefore, as the health of the female continues unmolested by copious menstruation, it cannot be accounted immoderate, or a proper object of medical attention; but when this evacuation gives rise to debility, exhaustion, and other symptoms of ill health, it amounts to a morbid discharge, and requires remediate measures. Immoderate flow of the menses must not be confounded with menorrhagia. This latter is, strictly speaking, a hsemorrhage, whilst the former consists in a mere superabundant secretion. of the natural or healthy menstrual evacuation. In menorrhagia the effused blood retains its power of coagulation, or at least shows a tendency to coagulate; but in immoderate menstrual discharge it remains liquid and entirely free from coagula. Menorrhagia is sometimes preceded by various premonitory symp- toms; such as pain and tension in the loins and pubic region; a feel- ing of fulness and pressing down in the uterus; frequent desire to pass urine; a small, contracted, and frequent—or a full, wave-like, or rebounding pulse; heaviness of the head; ringing and noise in the ears; slight and creeping chills, transient flushes, and sense of weight in the feet. In many instances, however, the hemorrhage commences without any indications of its approach. Sometimes a sudden gush of blood takes place, which continues to flow very copi- * R.—Prussiat. ferri. 3L G. aloes soc. gr. viii. Tart, antimon. gr. ii. Conserv. rosar. q. s. M. Divide into thirty pills. §!. Take two every morning, noon, and evening. MENORRHAGIA. 569 ously for a few hours and then ceases. More commonly, however, the discharge continues for four or five days, and in some instances several weeks, and goes off very gradually. When it occurs about the period of the final cessation of the menses, it is apt to become very protracted in its duration, more especially in females of ple- thoric and relaxed habits of body. All the consequences, that have already been mentioned as apt to occur from the excessive loss of blood, are especially prone to super- vene from uterine hemorrhage. Women of a nervous temperament are liable to sudden amaurosis from excessive uterine hemorrhage, and they are especially subject to a very peculiar nervous pain in the head over the region of the orbit of one side; and sometimes they become affected with a distressing jarring noise " like that of a mill or threshing floor." (Hall.) When menorrhagia is copious, and prolonged in its course, or recurs frequently at short intervals, it seldom fails to produce great relaxation and debilit)^, and to lead ultimately to a train of very distressing, and even dangerous affec- tions. Females who are much affected with this hemorrhage, become pale, sallow, wTeak,and dyspeptic; and in phlegmatic habits, oedema of the" feet, or general anasarcous effusion, pains in the sto- mach, with great muscular prostration, are apt to ensue. Leucor- rhoea, often extremely copious, almost universally occurs during the intervals of the hemorrhages, and contributes greatly to the general debility and relaxation. Menorrhagia may with much propriety be divided into active and passive* The former variety occurs in sanguineous, robust, florid, and healthy females, and is almost invariably preceded for a short time by the natural menstrual secretion. These cases rarely * Dr. Dewees thinks there is good reason to doubt the propriety of this " me- chanical distinction." He adopts the doctrine of Broussais, that all haemor- rhages are active, and quotes Dr. Caldwell in support of this opinion. Strictly speaking, there is, perhaps, no haemorrhage absolutely passive, and in which the vessels that furnish the blood do not co-operate in the production of the haemor- rhage by some kind of action. In a practical point of view, however, this dis- tinction is unquestionably both proper and useful. Would Dr. Dewees not Consider aloes a very improper remedy in the menorrhagia of young, sanguineous, and robust females'? He no doubt would. And why? Because experience has shown that this article is among our most efficient means for exciting the uterine vessels, and directing the afflux of blood to them. Yet this article, given in small, but frequent doses, deserves to be accounted the best remedy we possess for those protracted, exhausting, and obstinate uterine haemorrhages which occur in relaxed, nervous, and phlegmatic habits, about the critical period of life. When, therefore, we see a particular modification of this discharge arrested by a remedy which we are accustomed to regard as decidedly calculated to stimu- late the vessels from which it occurs—in other words, when we cure the haemor- rhage by exciting applications, we have good grounds for distinguishing it from those cases of the same affection which are invariably increased by its operation. Vol. I.—72 570 MENORRHAGIA. continue more than seven or eight days, and are often attended with considerable pain in the lower part of the abdomen, with a frequent and tense pulse, and a dry and feverish state of the skin. Passive menorrhagia is almost entirely confined to the period when the uterus is about losing its functions—and is met with only in such as have been much debilitated and relaxed by privations or previous diseases, particularly protracted and profuse leucorrhoea; or in individuals of a nervous or phlegmatic temperament, who have been subject to profuse catamenial or menorrhagic discharges. The pulse, in cases of this kind, is small and weak; the muscular system relaxed and debilitated; the skin cool and pale;, the countenance exsanguious, and expressive of anxiety and languor; the urine generally pale; and the stomach disturbed with frequent nausea, and other unpleasant sensations. The discharge is apt to continue for three or four weeks, and sometimes much longer. When in bed, the hemorrhage is usually moderate; but on rising, or making the least bodily exertion, the flow of blood is often suddenly increased. If the hemorrhage ceases, it is succeeded by a profuse leucorrhceal discharge, which is quite thin or watery. Causes.—Females of vigorous and sanguineous habits are more subject to menorrhagia than the feeble. The predisposition to this hemorrhage is much favoured, by whatever has a tendency to pro- duce general plethora, and by an irritable and relaxed state of the system. A luxurious and indolent life; the free use of high-seasoned and nourishing diet, wines, and cordials; tightly laced corsets; fre- quent and long indulgence in the warm bath; habitual costiveness, and inordinate sexual indulgence, are among the most common and influential predisposing causes of active menorrhagia. Copious and protracted leucorrhoea; mental depression; deficient and unwhole- some nourishment; habitual exposure to a cold or humid atmosphere; in short, every thing which is capable of relaxing and debilitating the general as well as the uterine system, may favour the occurrence of passive menorrhagia. Whatever tends to produce sanguineous congestion in the uterus may excite this hemorrhage; such as riding on horseback; dancing; active purgating; the use of emmenagogues; immoderate venereal indulgence; long and rapid walking; a fall on the hips; stimulating diet and drinks; a loaded and constipated state of the bowels; sup- pressed hemorrhoidal discharge; induration of the liver or spleen; and reading voluptuous novels, &c. Treatment.—The indications in this, as in the other varieties of hemorrhage are, to remove the predisposing and exciting causes if practicable; to lessen the momentum of the general circulation, if it be not below the natural standard; to derive the circulation from the uterine system; and finally, to constringe the bleeding vessels. If the pulse be active, or tense and quick, venesection will be proper; and every thing which has a tendency to excite the action of the heart and arteries must be removed. The patient should lie MENORRHAGIA. 571 on a mattress, avoid getting up or walking about, and take only the lightest kinds of liquid farinaceous nourishment and cooling accidu- lated drinks. Having diminished the momentum of the circulation, recourse must next be had to such remedies as experience has shown to be capable of constringing, or in some way or other checking the hemorrhagic action of the bleeding vessels. Among these, the sugar of lead holds the first rank, and will seldom disappoint our expectations entirely, in the active variety of the disease. From two to three grains, either alone or with a grain of ipecacuanha, may be given every half hour or hour, or at longer intervals, according to the rapidity of the hemorrhage. When the pulse is contracted and quick, it should be given in union with moderate doses of opium or Dover's powder. I have been in the habit of giving it in such cases with about a grain of camphor and the same quantity of ipeca- cuanha in each dose, with the view of exciting a gentle diaphoresis. The tincture of cinnamon is, perhaps, more frequently used by the German physicians in menorrhagia than any other remedy; and my own experience enables me to speak with much confidence of its usefulness in cases unattended with considerable arterial excite- ment. From thirty to sixty drops of it may be given every hour or two. I have, in some instances, known the discharge very promptly moderated by this medicine alone. A great variety of other astringent remedies are recommended in the books, for the treatment of this hemorrhage. Alum, the extract of rathany, kino, the sulphate of copper, &c. may, no doubt, be used with occasional advantage; but they are not equal to the sugar of lead for arresting sudden and rapid menorrhagic discharges. In cases attended with a moderate and protracted flow of blood, the extract of rathany will often afford much advantage; and in instances of this kind, I have also used alum, in union with ipecacuanha, with marked benefit* Tannin has lately been administered in uterine hemorrhage or menorrhagia, with marked success. M. Chavalier prescribed this article in doses of two grains every two hours, in a case of uterine hemorrhage, after a great variety of other remedies had been used with little or no advantage. " On the first day, some amendment was perceptible; on the second, the discharge was but very slight, and on the third day hemorrhage was completely arrested, giving place to an abundant leucorrhoea, but this also disappeared under the continued use of the tannin. M. Chavalier employed this remedy in several other obstinate cases of menorrhagia, and always with the happiest effecf't In cases accompanied with increased arterial ex- citement, the nitrate of jjotash, given in large doses, will often * R.—Pulv. sulph. aluminis. 9i. Pulv. ipecac, gr. xii.—M. Divide into six equal parts. Give one every three or four hours. f Revue Medicale, September 1828. 572 MENORRHAGIA. afford prompt relief. When the hemorrhage is profuse and rapid, cold applications to the vulva and region of the pubis should be made. We may also resort to cold and astringent injections into the vagina. When the violence of the discharge has been in some degree check- ed, and it continues in a moderate degree, the elixir of vitriol, diluted in cold water, may be taken at short intervals with advan- tage. Should the measures already indicated fail to arrest or suffi- ciently to moderate the hemorrhage, recourse must be had to the tampon. A strip of soft linen should be introduced by pushing it gradually into the vagina on the point of the finger, until the exit of the blood is obstructed. This will cause the formation of a coagu- lum, which, being immediately in contact with the bleeding surface, prevents the further progress of the effusion. Emetics also have been recommended for the suppression of uterine hemorrhage; and in active cases of a protracted character, attended with symptoms of gastric disorder, an emetic dose of ipecacuanha will occasionally do much good.* Perfect rest, a light simple diet, and cooling drinks, must be enjoined, and all mental agitation carefully avoided. In passive and protracted hemorrhage from the womb, attended with the symptoms mentioned above as indicative of this variety of menorrhagia, little or no permanent advantage can be obtained from astringent and cooling remedies. These hemorrhages are, indeed, often extremely obstinate in their course.. From much attention to cases of this kind, lam satisfied that the appropriate remedies are such as tend to invigorate the uterine vessels. Blisters to the sacrum will, in some instances, do much good; but the remedy which has most frequently succeeded in my hands, is a combination of aloes and the prussiat of iron,t in conjunction with the tincture of cinna- mon. With these medicines I have often succeeded promptly in arresting such hemorrhages. Dr. Dewees recommends small doses of hierapicra, a combination which I have known very effectual in several cases. Aloes is an old remedy in this variety of hemor- rhage. Bur'dach, in his Materia Medica, mentions its usefulness in such cases. Ergot may also be used with a prospect of advantage; and I have even resorted to the more active emmenagogues, such as the extract of savin, with evident benefit; and in no instance with disadvantage. The savin has indeed been highly recommend- ed by several German writers, in uterine hemorrhages of this kind. Dr. Feist asserts, that in menorrhagia of long continuance, attended with a sluggish and relaxed habit of body, and a pale and fetid dis- charge, prompt and complete relief may, in general, be obtained * Eberle's Mat. Med. vol. i. p. 27. Second edition. X R.—Prussiat ferri 3L G. aloes, gr. v. Conserv. rosar. q. s.—M. Divide into 20 pills. Take one three times daily. PHLEGMASIA DOLENS. 573 from the use of savin.* He recommends the following formula for administering this article. R — Pulv. folior sabin. Jjiii. Extract, sabin. £ii. 01. Sabin. ^i.—M. Divide into three grain pills. Take four three times daily. Dr. Gunther, of Cologne, also, has published an account of some cases of profuse and long-continued menorrhagia which yielded to the extract of savin given in scruple doses.t The prussiat of iron, in doses of from ten to fifteen grains, has been employed by some practitioners with much success; and 1 do not doubt, from what I have seen of its powers, that it may be very beneficially given in this form of passive hemorrhage. We may also resort to the muri- ated tincture of iron in cases of this kind. I have lately succeeded in putting a stop to a protracted hemorrhage of this kind, by a rpix- ture of the compound tincture of aloes and the muriated tincture of iron, according to the following prescription. R.—Tinct. aloes compos. ---ferri. muriat. aa^ss__M. Take twenty drops four times daily. —-.»►©©©•«•.— CHAPTER XX. PHLEGMASIE OF THE LYMPHATIC SYSTEM. Phlegmasia Dolens. This singular phlegmasial affection is almost exclusively confined to females in the puerperal state; and is characterized by a pale, tense, elastic, and extremely tender swelling of one of the inferior extremities; communicating to the touch a feeling of numerous in- durated nodules and ridges under the skin; and attended with more or less fever, usually of a hectic character. As has just been stated, phlegmasia dolens is almost exclusively a puerperal affection; and it appears from general observation, that the most common period of its attack varies between the fifth and ninth days after parturition. It is asserted by some writers (Good,) that this disease " has never been known to affect any other part of the body than the lower extremities;" but Carus and some other authors mention instances of its occurrence in the superior extremi- ties. * Gemeinsame Deutsche Zeitschvift fur geburtskunde. X Rev. Med. Jan. 1827. 574 PHLEGMASIA dolens. In general, the first manifestations of the disease are: pain and stiffness in the groin of one side, preceded or accompanied with chills, or strong rigours, followed speedily by the ordinary train of pyrexial symptoms. Occasionally, though rarely, the disease com- mences by pain and swelling in the foot, an instance of which I saw about fifteen years ago. Wherever the starting point of the disease may be, the swelling more or less rapidly extends itself over the whole limb, and continues to increase until the extremity becomes enormously distended and exquisitely painful to the touch. To the sight the swelling exhibits an even and uniform surface; but when the hand is lightly passed over it, a number of hard ridges and little indurations are felt, apparently immediately, under the skin. The skin presents a pale or white, smooth, and glabrous appearance, and is preternaturally warm to the touch. In general, the swelling ex- tends to the labium pudendi of the affected side, leaving the opposite labium and contiguous parts entirely free from tumefaction and pain. More or less tenderness is generally felt in the iliac region of the affected side, and the track of the round ligament is especially apt to become painful or tender. Mr. Trye, indeed, considers the ten-! derness in the course of the round ligament as a pathognomonic symptom. Position produces no change in the swelling, as is the case in oedema. When the disease is at its height, the skin of the affected limb is much whiter than that of the sound side; and its temperature is always very considerably augmented. The disease is always attended, from its commencement, with considerable irri- tative fever, and the patient is generally extremely restless, and tor- mented by her sufferings. The duration of the disease is very variable. It seldom, however, terminates under two weeks; and it may be prolonged to the fifth week, and even to a longer period. When it is about declining, slight sweats break out over the whole surface of the body, and the urine deposits a reddish sediment, whilst the fever progressively abates. The declension of the swelling is always very gradual, and the leg very rarely returns to the size of the sound one. Some degree of stiffness of the muscles of the leg usually remains after the total subsidence of the disease; and the skin continues for many months to be less moveable on the subjacent parts than in the sound state. In some instances, though very rarely, the inflammation termi- nates in suppuration; and when this happens, the cellular membrane sloughs out from between the skin and muscles, as in the suppura- tion of erysipelas. The occurrence of this accident is always at- tended with the utmost danger. The only two fatal cases I have ever seen, terminated in this way—a termination which, in both instances, was caused by the ruinous treatment of an empiric, under whose mismanagement the cases were placed. In general the breasts become flaccid, and the secretion of milk is in part, or even wholly, suspended. It is singular that this fact PHLEGMASIA DOLENS. 575 should be denied by Dr. Good; for I can affirm, that I have never met with an instance of this malady, in which the lacteous secretion was not conspicuously diminished". Dr. Huston of this city, in a well written and interesting paper on this disease,* declares that "in all the cases he has seen, the secretion of milk was diminished, and in some wholly suspended during the violence of the disease;" and the same observation is made by nearly every writer on this subject I have consulted. In relation to the etiology and nature of this affection, writers have expressed a great variety of opinions. By many the disease has been ascribed to a metastastic transference of the lacteous secre- tion, from the breasts to the affected limb, giving rise to the deposi- tion of milk into the cellular tissue of the extremity. This opinion was advocated by Puzos, Levret, Astruc, Doublet, Mauriceau, and by nearly all the German writers on this subject, until a very recent date. Others have ascribed the disease to an obstruction of the lymphatics at the brim of the pelvis, by the pressure of the child's bead during parturition, giving rise to over-distention and conse- quent rupture of the lymphatics, whence effusion and accumulation of lymph in the glands and cellular tissue of the limb ensue. This doctrine was advanced by Mr. White of Manchester; but its fallacy has been abundantly exposed by various writers. Denman and others maintain that phlegmasia dolens consists essentially in lym- phatic inflammation, commencing in one or more lymphatic glands in the groin, and thence extending along the lymphatic branches, until the whole limb becomes affected. The primary inflammation of the inguinal glands is excited, he thinks, by the acrid matter which is absorbed from the vagina. Dr. Hull conceived the disease to consist of inflammation of the muscles, cellular tissue, and inferior surface of the cutis, giving rise to a sudden effusion of serum and coagulable lymph into the cellular texture of the extremity; and according to Dr. Hosack, the inflammation occurs in all the struc- tures of the limb—in the blood-vessels, absorbents, muscles, cellular membrane, skin, &c. In relation to this latter opinion, Dr. Huston very justly observes, that it is difficult " to conceive of an inflamma- tion of all the blood-vessels of a limb, without the appearance of redness; or of such extensive inflammation as that involving every tissue of a part, without its termination in suppuration, gangrene, or other bad consequences, far more frequently than happens in phleg- masia dolens." More recently, Dr. Davies of London has published some observations tending to show that phlegmasia dolens is the result of an inflammation of one or more large veins, " terminating in the formation of artificial membranes and other obstructions within their cavities, whereby the free return of the blood from the extremity is prevented." This doctrine is also sanctioned by M. Velpeau; but the phenomena of phlebitis are certainly very different from * North American Medical and Surgical Journal, vols. iv. and v. 576 PHLEGMASIA DOLENS. those which characterize phlegmasia dolens; and there docs not, on comparing these affections, appear to exist any reasonable grounds for this opinion. (Dewees, Huston.) Whatever we may think of the mode of origin, or the location of the morbid condition which constitutes this affection, there can be no doubt that it is essentially an inflammatory affection; and there exists the highest degree of probability, that the whole system of lymphatic vessels of the limb is engorged and greatly distended with lymph, at the same time that some effusion may occur into the sub- cutaneous and intermuscular texture. The following sentiments, expressed by Dr. Huston, are entirely accordant with my own views on this subject, and as they embrace a clear summary of the argu- ments on this point, I cannot do better than to adopt his language. "I believe it to consist in a complete '•engorgement* of the whole lymphatic system of the affected limb; produced by an inflamed condition of the different conglobate glands, through which the chief lymphatic vessels have to pass, on their way from the affected part, to the thoracic duct. "This inflammation may occur either primarily in one or more glands, or first in a principal lymphatic trunk, and thence extend to the glands. And this may originate either, 1st, from the gland or lymphatic trunk being bruised by the passage of the child's head through the pelvis during labour: or 2d, from exposure to cold, and especially a damp or humid atmosphere; or the putting on of ill- dried clothes, during the irritable condition of the female system which attends the puerperal state: or 3d, from the absorption of some acrimonious matter, whereby the internal surface of the lympha- tics themselves may be excited to inflammation, and thence extend- ed to their appropriate glands; or the matter may be transmitted to the glands, and there excite inflammation. My reasons for the opi- nions which have been advanced, are briefly as follow: " 1st. The fact of every woman's exposure to one of the preceding exciting causes, and frequently to all of them. "2d. The uniform occurrence of pain or uneasiness about the passage of the round ligament, in the groin, and down the inside of the thigh, preceding the existence of swelling or other affection of the limb whatsoever: showing conclusively the priority of disease in the glands and their communicating trunks. " 3d. The white colour of the affected limb: which can only be accounted for satisfactorily, by supposing an 'engorgement' of the vessels which carry white fluids; for were it congestion of the blood- vessels, as in ordinary inflammation, there would necessarily be redness, instead of the white aspect. " 4th. The state of the woman's system generally, as the pulse, tongue, hectic form of fever, &c, all of which manifest a state or condition totally different from what is observed in cases of high and unequivocal inflammatory action; evidencing a state of irrita- tion, or inflammatory action of a low or subacute character. This PHLEGMASIA DOLENS. 577 state of irritation may be readily accounted for, by the great disten- sion of the lymphatic vessels of the limb, throughout their utmost ramifications, and the consequent pressure which must thence be made upon the immensity of nervous fibrils by which they are sur- rounded. "Lastly. Its termination; which is far more uniform, and less fatal, than an equal extent of inflammation, attended with congestion of the blood-vessels seated in any part of the body; proving, incon- testibly, that it must have a course peculiar to itself; which course, very commonly commencing by a diminution of pain in the iliac and inguinal regions, and next of the swelling of the parts nearest those glands, indicates very clearly the seat of the disease to be in the lymphatic system, and especially the conglobate glands." This doctrine does not differ materially from the views given of the pathology of this affection by Trye, Capuron, Gardien, and Denman. The following appearances were noticed on post-mortem exami- nation of a woman who died of this disease soon after parturition. No remarkable morbid appearance in the uterus, excepting a very turgid state of the spermatic veins, which were very large and tor- tuous; " the vena cava was healthy, down as far as its juncture with the renal vein, below which it was thickened, and filled with a fibrous substance, varying in consistence, and adhering to the inner coat of the vessel. On laying bare the femoral vein the subcutane- ous cellular tissue was found to be infiltrated with serum, the gra- nules of fat much firmer and more distinct than natural, and the intervening cellular membrane thickened and opaque. The lympha- tic glands in the groin were large, full of serum, and closely matted together by a condensed cellular membrane. It was extremely diffi- cult to detach the iliac, femoral, and suphena veins, in consequence of their strong adhesions to their sheath, and the surrounding organ- ized lymph, in which they were imbedded." These, together with the popliteal vein, were similar in condition to the inferior cava, ex- cept that the substance they contained was thinner, of a brown colour, and somewhat purulent dppearance. In the remainder of the suphena, and in the veins near the foot, there was a plug of coagu- lum; they were otherwise healthy. The iliac and femoral arteries contained a small quantity of blood; the other arteries were empty.* Treatment.—From what has been said concerning the general character of this disease, it is obvious that the treatment must be decidedly antiphlogistic. Blood-letting, both general and local, are required during the early stages of the complaint. The momentum of the circulation should be at once adequately diminished, by an efficient abstraction of blood with the lancet; after which it will be especially useful to apply leeches to the affected limb, particularly about the groin, and along the track of the principal trunks of the * Lond. Med. and Surg. Jour. April 20, 1833. Vol. I.—73 578 PHLEGMASIA DOLENS. lymphatics. Dr. Dewees advises that the leeches should be dis- persed over the limb, "that their bites may not be too near each other, as they sometimes leave troublesome sores." This precau- tion is very proper; as I have myself known very obstinate and ex- tensive ulceration to proceed from a number of leech-bites near the groin, in a case of this kind. In some instances th% febrile reaction, though not apparently very vehement, yields with great difficulty; and many venesections are required before the pulse can be suffi- ciently reduced. Dr. Dewees has found it necessary to bleed six or seven times before the disease yielded; and in a case which I treated about six years ago, five copious bleedings were required before an adequate impression was made on the pulse. Purgatives should be freely used during the active stage of the disease. Dr. Dewees prefers the following mixture for this pur- pose.* In one instance I used the magnesia in union with the tincture of colchicum, with peculiar benefit. The patient was order- ed to take a drachm of magnesia, with thirty drops of the tincture, every two hours. After the third dose, free purging ensued; and the result both in diminishing the general phlogistic habit, and miti- gating the local symptoms, was much more conspicuous than 1 had ever before witnessed from purgatives, or from any other remedy in this affection. I have not since had an opportunity of repeating this practice. In general, the purgatives should be of the saline kind. Diaphoretics, more especially antimony, may be employed with considerable advantage in the early periods of the disease. Tart. emetic, given in as large doses as the stomach will bear, without causing vomiting, is highly recommended by some writers, and I do not doubt its utility, during the active stage of the complaint. The following mixture forms an excellent diaphoretic, where, after decisive blood-letting, there is much general irritation.t Some writers have recommended emetics; but unless there are especial indications present for their employment, it does not appear that they are capable of procuring any material advantages. In debilitated and irritable subjects, and after proper depletory measures, in the more robust and phlogistic, opium is often highly serviceable to allay the excessive pain and general irritation which usually attend this affection. This narcotic may be very properly given in union with nitre and ipecacuanha; or, what is still better, in the form of Dover's powders, in combination with nitre. It must be particularly observed, however, that opium is in general decidedly * R.—Sulph. magnes. Magnesiae alb. ust. aa giii.—M. Div. in chart, iii. One of these to be taken every two hours, until they operate freely. , X R.—Pulv. ipecac, compos, gr. xxiv. Calomel, gr. iii. Pulv. nitrat. potass. £i.—M. Divide into eight equal parts. S. Take one every two hours. PHLEGMASIA DOLENS. 579 objectionable, so long as the general and local inflammatory symp- toms remain considerable; but in the decline of the disease, its effects are almost always highly soothing and beneficial. Among the external local remedies employed in this affection, besides the leeching already mentioned, fomentations with flannel, wrung out of hot vinegar and water; the application of a strong solu- tion of muriate of ammonia in equal parts of vinegar and water; and, after the pain, heat, and swelling begin to abate, moderately stimu- lating lotions—such as camphorated mixture diluted with an equal portion of brandy or whiskey, &c, may be accounted the most bene- ficial. Some writers strongly recommend the early application of blisters to the groin and to different parts of the extremity; whilst other writers, and amongst these Dr. Dewees, condemn this practice as rarely beneficial, and often decidedly injurious. My own ex- perience does not enable me to say any thing in favour of blistering in this complaint, although I have never known any manifest harm to result from it. Where the pain in the extremity is very great, much relief may sometimes be obtained by bathing the limb with laudanum, more especially after proper evacuations have been pro- cured. Emollient poultices have also been recommended for the purpose of allaying the pain, as well as assisting in the dispersion of the swelling; but in the early periods of the disease, this application appears to me calculated to do much mischief. The two cases already mentioned as having terminated in extensive suppuration, and ulti- mately in death, were treated from the commencement with poul- tices; but as all depletory measures were neglected, much of the mischief, no doubt, depended on the want of proper antiphlogistic means. After the fever, heat and pain have in a great degree sub sided, emollient applications in the form of a poultice may contribute in some degree to the removal of the stiffness and tension of the affected limb; but this purpose is much more effectually answered by frictions with dry flannel; the application of a muslin roller, pre- viously saturated with a strong solution of salt, and dried, to the whole limb; and fumigations of the extremity with the fumes of burning rosin. During the febrile stage of the disease, the diet must be of the simplest and weakest kind. During convalescence, the aliment should be digestible and nourishing, and when the patient is left in a very debilitated state, gentle tonics may be administered. If the weather is favourable, and the patient sufficiently recovered, exercise by ges- tation will be highly beneficial. END OP VOLUME I. VALUABLE MEDICAL BOOKS, PUBLISHED BY GRIGG & ELLIOT, No. 9, North Fourth Street, PHILADELPHIA. The DISPENSATORY of the UNITED STATES : consisting of, 1st, A TREATISE ON MATERIA MEDICA, or the Natural, Commer- cial, Chemical, and Medical History of the Substances employed in Medicine. 2d, A TREATISE ON PHARMACY: comprising an account of the pre- parations directed by the American and British Pharmacopoeias, and designed especially to illustrate the Pharmacopoeia of the United States. By George B. Wood, M. D., Professor of Materia Medica and Pharmacy in the Philadelphia College of Pharmacy; and Franklin Bache, M. D., Professor of Chemistry in the College of Pharmacy, and in the Franklin Institute. The above is one of the most valuable works of the kind ever issued from the American press. Dr. Eberle of Cincinnati, Ohio, remarks in the new edition just published of his invaluable work on Therapeutics, &c, that " he has availed himself freely of the various and accurate information embodied in the Dispensatory of the United States, by Drs. 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We cannot refrain from expressing our firm conviction, that, as a whole, this Dispensatory is the best work in the English language, on the subjects of which it treats; and we know of no work so well calculated, in the eyes of our neigh- bours of Europe, to raise the character of American science. COOPER'S FIRST LINES of the PRACTICE of SURGERY: de- signed as an introduction for students, and a concise book of reference for prac- titioners. By Samuel Cooper, M. D. With Notes, by Alexander H. Stevens, M. D., and additional Notes, and an Appendix, by Dr. S. M'Clellan. Third American, from the last London edition, revised and corrected. With several new plates and wood cuts, in 2 vols. 8vo. This work is highly esteemed by all the distinguished of the medical pro- fession ; and, in many of our Medical Schools, is used as a Text Book. A TREATISE ON THE MATERIA MEDICA and THERAPEUTICS, in 2 vols., 4th edition, improved and greatly enlarged. By John Eberle, M. 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